Mobile Units Enrollment Form 2023

Mobile Health Medical & Dental Clinics

Registration, Consent for Services and Disclosure of Personal Health Information
Name:

First NameMiddle NameLast Name
Gender:

MaleFemalePrefer not to say
Date of Birth:

MonthDayYear
Patient Ethnicity:

Hispanic or LatinoNot Hispanic or Latino
Patient Race:

Asian IndianChineseFilipinoJapaneseKoreanVietnameseOther AsianNative HawaiianOther Pacific IslanderGuamanian or ChamorroSamoanBlack/African AmericanAmerican Indian/Alaska NativeWhiteMore than one raceUnreported/Prefer not to disclose race
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
E-mail
example@example.com
Parent/Guardian Name:

First NameLast Name
Parent/Guardian Date of Birth:
School/Site:
Grade:
INSURANCE INFORMATION:

Please include all insurances if you have multiple forms of coverage.
MedicaidOther Insurance
If "Other Insurance", name of Insurance:
ID #
Group Number:
Contract Number:
Name of Insurance Holder:
Employer:
HEALTH HISTORY:

Please check each condition applicable to the patient.
Type a question

AsthmaArtificial JointAIDS/HIVBehavioral ProblemsBleeding DisorderCerebral PalsyCongenital Heart Disease/DefectDiabetesEpilepsy/SeizuresHearing Loss/DifficultyHistory of Heart Attack or StrokeHepatitis/Liver DiseaseHeart Surgery/ProblemsKidney/Bladder DiseaseMouth/Tooth PainNausea/VomittingPacemaker/Implanted DevicesPregnant/NursingPsychiatric/Psychological CareRadiation/Chemo TreatmentsTuberculosis/EmphysemaVision Difficulties
CURRENT MEDICATIONS - List all:
ALLERGIES - List all:
SURGERIES - List all:
If consenting to medical care, FHC will verify if the patient is up to date on required and recommended vaccinations. Please confirm your vaccination approvals below. You will be notified if your youth is given immunizations.
I approve the following:

ALL vaccinationsONLY marked vaccinations (please indicate by marking check boxes below)NO vaccinations
REQUIRED for school entry:

Diphtheria, Tetnus, Pertussis (DTP, DTaP, Tdap)PolioMeasles, Mumps, Rubella (MMR)Hepatitis BMeningococcal Conjugate (MenACWY)Varicella (Chickenpox)
RECOMMENDED by the CDC and our FHC Providers:

Hepatitis AHPV (Gardasil)Meningitis BInfluenza (Flu)COVID-19
Services Available on the Mobile Medical & Dental Units

Primary Care Services:
1. Well Child Care and Early and Periodic, Diagnostic and Treatment (EPSDT) Screening and Exam
2. Comprehensive Physical Exams and Sports Physicals
3. Vision Screening
4. Hearing Screening
5. Health Education and Risk Reduction Counseling
6. Sexually Transmitted Disease (STD) Testing
Illness/Injury Care:
1. Minor Injury assessment, treatment and follow- up
2. Acute illness assessment, treatment, follow-up and/or referral
Chronic Conditions Care:

May include asthma, high blood pressure, obesity, allergies, skin conditions, etc.
1. Exam, diagnosis and treatment of a new condition
2. Maintenance and follow-up of existing conditions
Immunizations:
1. Screening and assessment using Michigan Care Improvement Registry (MCIR)
2. Administration of immunizations (with parent/guardian approval as indicated)
Dental and Oral Health:
1. Cleaning: The benefits include healthy gum tissue, elimination of odors and stains. After cleaning teeth and gums may be sensitive.
2. Flouride Treatment: Flouride varnish is painted on teeth to prevent tooth decay, delivering a safe and effective dose of flouride.
3. Sealants: Sealants help prevent decay on the chewing surface of a tooth.
Consent for Services

By signing I confirm that I am the patient over 18 or the parent/legal guardian of the patient named above. I confirm that I have the legal authority to give consent for their medical and dental care. I know that I can ask any questions about treatments that the patient may receive. I give the family Health Center (FHC) permission to do the following:
- Perform procedures and treatments that are deemed appropriate and to seek further emergency assistance, if needed.
- Release information regarding these services for purposes of receiving insurance payment.
- I understand I am responsible for charges not paid by insurance or will be billed based on my ability to pay.
- Allow dental or medical students under direct supervision of a licensed dental/medical professional to provide servies.
- As parent/guardian I understand that treament may be obtained at the patient's dental home/medical home rather than at the school clinic/mobile dental facility and that obtaining duplicate services at the clinic/mobile dental facility may affect benefits that the patient received from the medical/dental insurance.
- In an emergency, it is okay (I authorize) for an adult to seek medial help for my youth. If I have a question about any emergency related to my youth's medical or dental services, I may call the Mobile Unit Manager (269) 349-2641, Ext. 690.
- I understand that the Family Health Center Notice of Privacy Practices is posted online at https://www.fhckzoo.com/privacy-notice/. A hard copy can be obtained by calling (269) 349-2641.
This authorization will be kept on file and remain in effect until September 30, 2025. You have the right to have a copy of this form once it is signed. You have the right to cancel this consent or authorization at any time, in writing. If you cancel, it only applies to uses and services after cancellation date. If you would like a copy of this consent for your records, please call us at (269) 349-2641.
Please indicate which services you consent to for the patient:

Medical CareDental Care
Signature (Patient or Parent/Guardian if a minor)

Clear
Printed Name:
Date:
Relationship to Patient:

Parent/GuardianSelf
Should be Empty:

Mobile Health Medical & Dental Clinics

INSURANCE INFORMATION:

HEALTH HISTORY:

If consenting to medical care, FHC will verify if the patient is up to date on required and recommended vaccinations. Please confirm your vaccination approvals below. You will be notified if your youth is given immunizations.

Consent for Services