Queen Anne's County School Based Health & Dental Student Enrollment Form (English)

School Based Health / Dental Centers

Student Enrollment Information | Queen Anne's County Public Schools
Please review the following information before beginning the enrollment form.

School Based Health & Dental Centers are a partnership between Choptank Community Health and Queen Anne's County Public Schools. This program allows students to receive medical and dental care right at school. Care is coordinated with your student's primary care provider and/or primary dentist. Choptank Health will always obtain parent/guardian permission before seeing or treating your student.

Services available in the School Based Health & Dental Centers include:
- Diagnosis and treatment of illness, including referrals
- Health risk assessments
- Sports physicals & well visits
- Dental fluoride / sealants / cleaning
- Behavioral health services
- Lab tests for acute illness
- Support for chronic diseases
- Nutrition / dietician visits
- Health education
- Telehealth / virtual visits
ALL QACPS students are eligible to visit the School Based Health or Dental Center at ANY QACPS school.

To complete this enrollment form, you will need:
- Your student's health history, including medications, allergies, and recent surgeries
- Your family health history
- Health and/or dental insurance information, if applicable. NOTE: If your student does not have insurance, they are still eligible to receive services. You may apply for the Sliding Fee program, which provides discounted services based on household income.
If you have questions about the program, please contact Choptank Community Health System at 410-479-4306 Ext. 1038.

School Based Health / Dental Centers

Student Enrollment Form | Queen Anne's County Public Schools
I want to enroll my child in:*

School Based Health Center AND School Based Dental ProgramSchool Based Health Center ONLYSchool Based Dental Program ONLY
My child is a student at:*
My child's grade is:*
My child's homeroom teacher is:

Student Information
Student's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*

MonthDayYear
Gender*

MaleFemalePrefer not to respond
Social Security Number:
Race:*
Hispanic / Latino?*

YesNo
Preferred Language:*
Primary Care Doctor
Name of Doctor:
Doctor's Phone Number:
Please enter a valid phone number.
Primary Dentist
Name of Dentist:
Dentist's Phone Number:
Please enter a valid phone number.
Pharmacy
Name of Pharmacy:
Pharmacy's Phone Number:
Please enter a valid phone number.

Parent / Guardian Information
Parent / Guardian Name*

First NameLast Name
Relationship to Student:*
Preferred Language:*
Phone Number #1*
Please enter a valid phone number.
Phone Number #2 (optional)
Please enter a valid phone number.
Is it okay to text you?*

YesNo
Email
example@example.com
Emergency Contact Information
Name of Emergency Contact*

First NameLast Name
Relationship to Student:*
Phone Number #1*
Please enter a valid phone number.
Phone Number #2 (optional)
Please enter a valid phone number.

Health Insurance Information
Does your student have health insurance?*

YesNo
NOTE: If your student does not have health insurance, they are still eligible to receive service. You may apply for the Sliding Fee program later in this form.

If you have health insurance but do not have your insurance information available at this time, you may provide it at a later date.
Insurance Name:
Policy / Member ID Number:
Group Number:
Subscriber Name:

First NameLast Name
Subscriber Date of Birth:

MonthDayYear
Claims Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dental Insurance Information
Does your child have dental insurance?*

YesNo
NOTE: If your student does not have dental insurance, they are still eligible to receive service. You may apply for the Sliding Fee program later in this form.

If you have dental insurance but do not have your insurance information available at this time, you may provide it at a later date.
Insurance Name:
Policy / Member ID Number:
Group Number:
Subscriber Name:

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Claims Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sliding Fee Information

If you are not interested in applying for the Sliding Fee, please click "Next" at the bottom of the page. Patients on the sliding fee program can receive discounts that are billed based upon their income. All patients and their families are eligible to apply for the sliding fee program, even if they have insurance.
Would you like to apply for the Sliding Fee?

YesNo
If yes, number of people in your household:
If yes, annual household income (enter number only):

Consent & Signature

By signing below, you agree:
I understand that my signature gives consent for the CCHS School Based Health/Dental Center Providers to treat my child and to communicate with my child’s primary health care provider. I give CCHS permission to call my home, leave a message regarding healthcare information. CCHS may also mail healthcare information to my home.

I understand that my child’s health information will be used for treatment, payment and health care operations.

I recognize that school directories will be used to obtain information left blank on the enrollment form.

My child’s immunization record may be shared between the School Nurse and the School Based Health/Dental Centers. For the purposes of care coordination and case management, School Clinical Staff will have access to the SBHC/SBDP health records and School Clinical Staff shall share health information with the SBHC/SBDP staff. School Clinical Staff are required to treat the information in the SBHC/SBDP health record as confidential and comply with the HIPAA Privacy Rule and the FERPA Act.

I understand the student may request that visits remain confidential. Maryland Law does not require parental consent for treatment or advice about drug abuse, alcoholism, sexually transmitted diseases, pregnancy, or contraception. Students age 12 and over may receive mental health services without parental consent. Under no circumstances do SBHC/SBDP records become part of the student’s school health record.

I understand that services provided to my child will be billed to my insurance carrier or Medical Assistance. I may receive a bill from CCHS for copays and/or deductibles.

I understand that my signature indicates that I have had the opportunity to receive and review the Choptank Community Health’s Notice of Privacy Practices. We participate in the CRISP health information exchange ("HIE") to share your medical records with your other health care providers and for other limited reasons. You have rights to limit how your medical information is shared. We encourage you to read our Notice of Privacy Practices and find more information about CRISP medical record sharing policies at crisphealth.org.

If I do not have insurance, visit costs will be billed for the full cost of services or at a reduced rate with a sliding fee discount, if applicable. I will be offered a Sliding Fee Application whether or not I have health/dental insurance.

Our privacy forms can be found online at choptankhealth.org/formsinformation.
Signature*

Clear
NOTE: If you need to enroll another student, click the "Submit" button below, then click the "Enroll Another Student" button on the next screen.
Should be Empty:

School Based Health / Dental Centers

School Based Health / Dental Centers

Student Information

Primary Care Doctor

Primary Dentist

Pharmacy

Parent / Guardian Information

Emergency Contact Information

Health Insurance Information

Dental Insurance Information

Sliding Fee Information

Student's Health & Dental History

Family History

Consent & Signature