MediCentral JCBOE Services Pre-Registration

1
Name of School* This field is required.
Please Select
Please Select
PS 3 - Frank R. Conwell School
PS 5 - Dr. Michael Conti School
PS 6 - Jotham W. Wakeman School
PS 8 - Charles E. Truefurt School
PS 11 - Martin Luther King Jr. School
PS 20 - Dr. Maya Angelou School
PS 24 - Chaplain Charles Watters School
PS 25 - Nicolas Copernicus School
PS 27 - Alfred Zampella School
PS 28 - Christa McAuliffe School
PS 30 - Alexander D. Sullivan School
PS 33 - Dr. Paul Rafalides
PS 34 - President Barack Obama Elementary School
PS 37 - Rafael De J. Cordero Elementary School
MS 4 - Frank R. Conwell Middle School
MS 7 - Franklin L. Williams Middle School
Infinity Institute
N.J. Regional Day School: Gerard J. Dynes
2
Child's Full Name* This field is required.
First Name
Last Name
3
Child's Date of Birth* This field is required.
Date
Month
Day
Year
4
Cell Phone Number* This field is required.
Please enter a valid phone number.
5
Patient's Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Email* This field is required.
example@example.com
7
Gender* This field is required.
Male
Female
Transgender
Non-binary
8
Do you have an active health insurance?* This field is required.
YES - INSUREDNO - UNINSURED
9
Insurance Card (Front)Please take a photo of your insurance card. Allow access to camera and when image is in focus please take photo.
10
Driver's License or Photo ID for Patient or Legal Guardian. * This field is required.Please take a photo of your Driver's License or ID. Please allow access to the camera. When the image is in focus press take photo.
11
Previous Medical History* This field is required.
Please Select
Please Select
None
Yes - Listed below
Please select whether your child has any previous medical history.
Specify your child's medical history if the answer above is 'Yes - Listed below'
12
Current MedicationPlease write any medication that your child is taking at the moment. If patient is not taking any medication, please write NONE
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13
Drug AllergiesPlease write any drug allergies that your child has. If patient has no drug allergies, please write NONE.
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14
SurgeriesHas your child had any surgeries in the past? If patient had no surgeries, please write NONE.
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15
HIPAA Privacy Authorization* This field is required.HIPAA Privacy Rule of Patient Authorization Agreement Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a)) I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as: a basis for planning my care and treatment; a means of communication among the health professionals who may contribute to my health care; a source of information for applying my diagnosis and surgical information to my bill; a means by which a third-party payer can verify that services billed were actually provided; a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals. I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me. I authorize The MediCentral to send school notes directly to the school nurse. Privacy Rule of Patient Consent Agreement Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a)) I understand that: I have the right to review this Practice’s Notice of Information practices prior to signing this consent; that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested; I have the right to object to the use of my health information for directory purposes; I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested; I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon. This authorization is valid from date of signature until the end of the school year 2023.
16
Patient Consent for Treatment and Use and Disclosure of Protected Health Information* This field is required.I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize The MediCentral to render necessary evaluation and treatment to myself/child/ward. I consent to the Health Service and HIPPA Privacy Notice. The practice will bill my insurance company for its services, if applicable. I consent to all communication, including but not limited to communication about my medical condition and advice from my health care providers by the following means; Voice, text and email. I hereby give my consent for The MediCentral (the Practice) to use and disclose my child's protected health information (PHI) to perform treatment, payment and health care operations (TPO). With this consent, the Practice may call me or email me to my home or other alternative location and leave a message by voice, email or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything pertaining to my clinical care, including laboratory test results With this consent, the Practice may mail to my home or other alternative location any items that assist the practice in performing TPO, such as appointment reminder cards, patient statements and anything pertaining to my child's clinical care as long as they are marked "Personal and Confidential." By signing this form, I am consenting to allow the Practice to use and disclose my PHI to carry out TPO. I may reboke my consent in writing except to the extent that the Practice has already made disclosures upon my prior consent. If I do not sign this consent, or later revoke it, the Practice may decline to provide treatment to my child. This consent is valid for all visits from date of signature until the end of the school year 2023.
17
Parent or Guardian's Signature* This field is required.
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18
Parent or Guardian's Full Name* This field is required.
First Name
Last Name
19
Signed on* This field is required.
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