Bear Care Nutrition Appointment

Located in White Bear Lake Area High School

5045 Division Ave., White Bear Lake, MN 55110

Enter MAIN ENTRANCE/DOOR A

Nutrition counseling appointments are for students of all ages in the White Bear Lake Area School District. All nutrition health services are of no cost to the patient/family.

(651) 653-2923

BearCare@RiseUpHealthClinics.org

Students under the age of 18 require parent/guardian consent for health services. Students 18 years and older may consent themselves. Consent forms will be sent to patients or the parent/guardian prior to the appointment.
Nutrition Appointment
What would you like to talk about at your appointment?*

General NutritionSpecial Dietary Needs (allergies, intolerances ect)Sports PerformanceNutrition and Mental HealthNutrition on a BudgetAssistance with WIC, SNAP and other servicesOther
Please provide any additional details about what you would like to discuss.

Select an appointment time*

Patient Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Have you been a patient at the Bear Care Clinic in the past? [For any service.]

Yes, I am a returning patient to Bear Care.No, I have never been to Bear Care.I am not sure.

Insurance Information

Please bring your insurance card to the appointment. Note -- if you have given your insurance information to the school district, we do NOT have that information.
Does the clinic have your health insurance on file?*

Yes.Yes, but my health insurance has changed. I will enter the updated information below.No. I will add my information below.
Please upload a photo of the FRONT side of your insurance card.

Cancelof
Please upload a photo of the BACK side of your insurance card.

Cancelof
Insurance Provider (for example, BCBS, HealthPartners, UCare)
Group Number
Policy Number
Date Policy Effective From
Policy Holder's Name
Policy Holder's Birthdate

By signing this form, you agree to the following:
- I authorize Rise Up Health Clinics (which operates the Bear Care Clinic) and its staff to provide necessary examinations, treatments, procedures, and care as deemed appropriate by the healthcare providers.
- I have the right to refuse or discontinue treatment or care at any time. However, I acknowledge that doing so may have potential risks or consequences, which your healthcare provider will explain.
- If I have any questions about the care provided, I will ask the healthcare provider.
- I consent to receive communications from the clinic, including appointment reminders, follow-up calls, and billing inquiries.
- Rise Up Health Clinics may use student health records to evaluate the quality of care and program effectiveness.
- The patient's school may give class schedule and immunization information to Rise Up Health Clinics only when necessary to provide patient care.
- Rise Up Health Clinics may share immunization information only with the patient's school.
- Immunization information may be shared through the Minnesota Immunization Information Connection (MIIC) with healthcare providers, schools, health departments, and others authorized under law to receive it.
- If receiving COVID-19 or other communicable disease testing, I acknowledge that the results are required by law to be sent to the Minnesota Department of Health for reporting.
- I acknowledge that a copy of the Notice of Privacy Practices and the Patients’ Rights and Responsibilities document has been made available to me (see final screen after signature and clinic website).
- I understand that Rise Up Health Clinics will bill my health insurance directly for services rendered. I agree to provide accurate and complete insurance information and notify the clinic of any changes to my insurance coverage.
- I understand that if I am able to, I can pay any copays or deductibles to the clinic. I understand that the patient will be able to receive health care services in the clinic regardless of my ability to pay or my health insurance status.
I acknowledge that this consent will remain in effect for two years; or, until the student reaches 18 or completes their high school career; or until changed by you (parent/guardian) in writing.*

Yes
I consent that the patient can now make their own appointments and receive care in the clinic as described above.*

YesNo
Printed name of parent/guardian or patient (or student if 18 years or older)*

First NameLast Name
Signature*

Clear
Should be Empty:

	Yes	No	Not applicable
Is the patient on Medicaid, Minnesota Care Programs, Prepaid Medical Assistance Plans, or Medical Assistance?
Is it ever challenging for your family to pay for health care services?
Does the patient quality for free or reduced school lunch?

Nutrition Appointment

Insurance Information