Family Medical Care School-Based Health Center Patient Form

Family Medical Care School Based Health Center
SBHC is a division of CHANGE, Inc.

CHANGE, Inc. is an equal opportunity provider & employer.

Administrative Office 3158 West Street Weirton, WV 26062

304-797-7733

www.changeinc.org
School Based Health Center Locations

Brooke County, Indian Creek Middle, Indian Creek High, Steubenville City, Toronto, Weir Complex, Weirton Elementary
Dear Parent and Guardians,

The staff at the CHANGE, Inc.'s Famliy Medcial Care School Based Health Centers are excited to assist your children with all of their health care needs Monday through Friday. Our licensed healthcare staff is on site in a safe, child-friendly environment. We closely work with the school nurse and faculty to provide convenient care to your child.

So what services are available?

Well check exams, sick visits, injury treatment, immunizations, allergy shots, ADHD evaluation and treatment, sports physicals, behavioral health, dental care, chronic health care maintenance- like being on site to assist with Diabetes, Seizures, and Asthma. Just think of us as a doctor’s office inside the school.

Parents can schedule appointments for their child before, during, or immediately after school. We welcome parents at the appointment, but a child can be seen without you present at your request. We recognize that parents work and there are transportation issues that create barriers to healthcare. We are more than happy to communicate with you via phone after seeing your child. So for example, the school nurse calls home stating that your child came to her with an earache. With your permission, the nurse can bring your child right over so we can evaluate to see if an infection is present. You can also call us or send a note to have your child’s teacher send him/her down to us for a visit as well.

What dental services are offered?

Our dentists schedule weekly appointments at our affiliated sites for a range of services which include cleaning, x-rays, state required dental assessments, and applying sealants to teeth.

How does the Behavioral Health Services work?

We have individual counseling on-site provided by a licensed behavioral health specialist. A referral can be provided from the parent/guardian, our healthcare providers, your local healthcare provider, or school staff. Some children have chronic issues like depression or anxiety, others have lost loved ones and need grief support, and others have been through personal crises like divorce or abuse. Our specialist can also assist with management of ADHD or disruptive behaviors such as arguing with adults and defiant behavior. An individualized plan will be developed for each situation.

What about my current doctor’s office?

We encourage all families to maintain a relationship with your current doctor. We understand however that it isn’t always convenient or possible to get your child to their office on short notice and we can help fill that gap.

All children enrolled in the school-based health services program are eligible to receive service regardless of insurance status. For children insured by CHIP or Medicaid, the services are covered 100% (no charge We accept most insurance plans. Our rate is the same as a physician office, which is likely less than urgent care and emergency room visits on most insurance copays. If you have no insurance, please ask about the CHANGE Inc. discount program.

Our goal is to have your child enrolled in the SBHC to help alleviate any barriers to receive healthcare. We will not be able to provide any services without your permission. The forms are to gather medical history and allow us the information to serve your child. You never know when an urgent health concern will arise. In order to obtain enrollment forms, you can stop in the office, call us to have them sent home with your child, or download at www.changeinc.org.

We look forward to meeting you and your children. We welcome you to stop by to ask questions and meet our staff. For questions please call 304-797-7733.

Family Medical Care School Based Health Center
Student’s Name*
Grade*
Birth Date*

MonthDayYear
Date
Gender:

MaleFemale
Social Security #*
Race
Ethnicity:

Non-HispanicHispanic
Preferred Language:
I authorize a physician assistant, physician, or designated health professional to provide necessary and/or advisable treatment for my child. I authorize release of written and verbal information relevant to my child’s health care between the school nurse and the health center’s staff only when necessary for his/her care. In case of emergency, every effort will be made by the health center staff to notify the parent/guardian. I understand the acknowledgement of Notice of Privacy Practices and know my minor child’s rights as a patient of the Weir Complex School Based Health Center. I authorize the health center to release information regarding treatment to third party payer such as Medicaid or insurance for the purposes of billing and for any reason in accordance with acceptable medical practice pursuant to the law. I assign my insurance benefits to be paid directly to the Family Medical Care CHC. I am financially responsible for non-covered services, but understand that services will not be denied due to inability to pay.
Address*

Student’s Home Address

Street Address Line 2

CityState

ZipCountry
Parent/ Guardian’s Name*
Preferred Phone #*

Country CodeArea CodePhone Number
Relationship to Patient:*
Housing Status*

Not HomelessHomeless ShelterPublic Housing(Not including Section 8)TransitionalOther
Email Address of Parent/Guardian*
example@example.com
Name of Emergency Contact in case parent/guardian cannot be reached*
Relationship to Child:*
Phone #*

Country CodeArea CodePhone Number
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Insurance Information:

Please send a copy of the insurance/medical card if possible
Mother/Guardian*
Mother’s SSN*
Birth Date*

MonthDayYear
Date
Cell #*
Home/Work #*
Father/Guardian*
Father’s SSN*
Birth Date*

MonthDayYear
Date
Cell #*
Home/Work #*
Private Insurance
Name of Insurance Company*
Address

Address

Street Address Line 2

CityState

Zip
Phone #*

Country CodeArea CodePhone Number
Employer/Company Name*
Name of Insured Employee*
Birth Date*

MonthDayYear
Date
SSN*
Policy Number*
Group Number*
MEDICAID
Straight Medicaid (Molina)
Unicare ID Number (begins with "W")
Health Plan ID Number (begins with an "H")
Carelink ID Number
WV Family Health Plan
CHIP ID Number
Co-Pay
No Insurance / Private Pay A sliding fee scale is available for families that are uninsured. Charges are based on income and family size. A copy of the parent/guardian’s proof of income must be on file with the application in order to be eligible our Change Inc. health benefits coordinator at 304-797-7733 for more information.

Family Medical Care School Based Health Center
Child Informed Consent Form
IFirst Name Last Name the parent/guardian of First Name Last Namegrant permission to utilize the medical, dental, and/or behavioral health services offered through the school-based health center.
Initialing each line and/or signing below, you acknowledge all of the following:
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
Initial* In general, any information that is about your health care you receive, or payment for that care, is considered confidential and protected by our practice. We may use your Protected Health Information to carry out treatment, payment, health care operations, and/or other purposes. Our “Notice of Privacy Practices” provides a more complete description of permitted uses and disclosures.
ASSIGNMENT AND RELEASE OF BENEFITS
Initial* I hereby authorize payment directly to CHANGE, Inc.’s Family Medical Care, for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, co-pays, and deductibles, whether or not paid by Insurance, and for all services rendered on my behalf or my dependents. I authorize the use of this signature on all insurance submissions.
PATIENT LIABILITY FOR NONCOVERED/INELIGIBLE SERVICES
Initial* I understand that the service I will be provided with via my Healthcare Provider or office staff may or may not be covered by my insurance. I understand that it is my responsibility to know my individual insurance plan’s covered services, and that CHANGE, Inc.’s Family Medical Care is not responsible to know whether my insurance will pay or require prior-authorization. If any services I receive at the facility at any time during my course of treatment are deemed non-covered or ineligible or any other reasons unpaid, as well as all efforts are made to obtain payment from my insurance, I understand I am financially responsible for payment of the denied services.
ELECTRONIC RECORD TRANSFER
Initial* I understand that it may be necessary to transmit my medical records/prescriptions electronically and I authorize to do so. I understand that if I need to transfer my medical records, that I am required to sign a separate Authorization to Release form with the Medical Records department. I absolve CHANGE, Inc.’s Family Medical Care, and its personnel of any liability relating to the transfer of said records.
AUTHORIZATION TO TREAT
Initial* I hereby authorize any provider employed as part of CHANGE, Inc.’s Family Medical Care Health Centers, to administer such treatment and perform such procedures as may be deemed necessary or advisable in the diagnosis of this patient which may or may not be myself.
AUTHORIZATION FOR EXCHANGE OF HEALTH & EDUCATION INFORMATION
Initial* I hereby authorize CHANGE, Inc.’s Family Medical Care to exchange health and education records (including immunization records) with the appropriate school district for the purpose of providing care and treatment, if applicable.
HIPAA RELEASE: I hereby authorize CHANGE, Inc.’s Family Medical Care Health Centers, providers and/or staff to discuss my medical information with the following person(s); This does not allow the release of records to this person(s)
Name*
Relationship to Patient*
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Patient’s/Guardian’s Signature*

Clear
Relationship to Patient*
Date*

MonthDayYear
Date

At CHANGE, Inc. much of our funding comes from government grants, so we must be able to provide estimated income information from all of the patients whom we serve. We will be asking you to provide this on a yearly basis.
Patient Name*
Date of Birth*
Date

MonthDayYear
Date
YEARLY INCOME

Check the correct box with your family size (number of people you claim on income tax) and yearly income range.
Please know that this information will be kept confidential! Thank you!
Should be Empty:

Family Medical Care School Based Health Center

School Based Health Center Locations

Family Medical Care

Family Medical Care School Based Health Center

Private Insurance

MEDICAID

Family Medical Care School Based Health Center

Child Informed Consent Form

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

ASSIGNMENT AND RELEASE OF BENEFITS

PATIENT LIABILITY FOR NONCOVERED/INELIGIBLE SERVICES

ELECTRONIC RECORD TRANSFER

AUTHORIZATION TO TREAT

AUTHORIZATION FOR EXCHANGE OF HEALTH & EDUCATION INFORMATION

YEARLY INCOME

Please know that this information will be kept confidential! Thank you!