Bear Care Nutrition Appointment

Billing Information

Our mission is to provide accessible, affordable care to youth. All children are able to receive health care services in the clinic regardless of their ability to pay or their health insurance status.

At this time, we are not billing for nutrition services. You will not receive a bill for the nutrition appointment.
Insurance status (for our records only - you will not receive a bill)*

I have health insurance through my employer.I have Medicaid.I have a state insurance (MN Sure or other state-offered insurance).I do not have health insurance.Other

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

Consent for Health Services

By signing this form, I 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 (no bill for nutrition services).
- 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 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 this consent will remain in effect for one year; or, until the student reaches 18 or completes their high school career; or until changes by me (parent/guardian) are made in writing.*

Yes
I consent that the patient can now make their own appointments and receive care with Rise Up Health Clinics as described above.*

YesNo
Patient Information

The Notice of Privacy Practices and the Patients’ Rights and Responsibilities have been made available to me via the link in this statement and on the clinic website.

https://www.riseuphealthclinics.org/patientinformation
By checking the box below, I acknowledge I have received access to the Notice of Privacy Practices and Patients' Rights and Responsibilities.*

Yes
By signing my name below, I consent to all the above information in this form.*

Clear

Is there any other information you want us to know about the patient before your Bear Care appointment?
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Bear Care Nutrition Appointment

Patient Information

Contact Information