Platte Purchase Middle School BTS Clinic Form

*Platte Purchase Middle School ONLY*
Before completing this registration form, please answer the following question to ensure that you are eligible for this clinic.
What type of insurance do you have?*
Please select which private insurance company you use:
We're sorry, we currently only accept Aetna, Blue Cross Blue Shield, Cigna, and United Healthcare Insurance Plans. Please reach out to your primary care provider to set up an appointment with them. We apologize for the inconvenience.

Patient Information
Student's Name*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Address*
Apt #
City*
State*
Postal/Zip Code*
County*
Example: Platte, Clay, Jackson, etc.
Home Phone*
If none, put cell phone number.Format: (000) 000-0000.
Cell Phone*
If none, put home phone numberFormat: (000) 000-0000.
Sex*
Gender*
Race*
Ethnicity*
Insurance Information
Insurance Type*
Medicaid DCN #
Private Insurance Information
Name of Primary Health Insurance
Name of Policy Holder
Policy Holder Phone Number
Format: (000) 000-0000.
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Address
Apt #
City
State
Postal/Zip Code
Policy or Member Numbers
Group Number
Customer Service or Provider Phone Number on back of the Insurance Card
Format: (000) 000-0000.
Authorization and Consent
Meningococcal ACWY (MCV4 ACWY) [Required 8th & 12th Grade]Tetanus, Diphtheria, Pertussis (Tdap) [Required 8th Grade]Human Papillomavirus (HPV) [Recommended 8th & 12th Grade]Hepatitis A (Hep A) [Recommended 8th & 12th Grade]
Personal Financial Responsibility: By signing this form, and in return for the services rendered by the Platte County Health Department (PCHD), I am personally responsible for all fees not paid by any third party on my behalf.

Assignment of Insurance Benefits: I hereby assign all my interest and rights to all insurance benefits otherwise payable to me from any portion of my medical, financial, or personal information to any person or organization requiring such information as a condition of paying, receiving payment for, or justifying payment for my health care or the health care of the one for whom I am responsible. I further authorize payment of all insurance benefits, otherwise payable to me, for all treatment provided directly to PCHD.

My signature indicates that I have reviewed a copy of the "Notices of Privacy Practices" and have read the Vaccine Information Statement(s) (VIS) and/or Emergency Use Authorization (EUA) for each vaccine that I am requesting be given to the person named on this form.
Name of Patient, Parent, or Legal Guardian*
Relationship to Student (self, parent, or guardian)*
Signature of Patient, Parent, or Legal Guardian*

Clear
Date*

MonthDayYear
Date

Screening & Questionnaire
School Name*
Student Name*
Student Date of Birth*

MonthDayYear
Date
Do you have allergies to medications, food, a vaccine component, or latex?*
If yes, what is your student allergic to and their reaction to it?
Have you had a serious reaction to a vaccine in the past?*
Do you have a health problem with lung, heart, kidney, or metabolic disease (i.e., diabetes), asthma, a blood disorder, or are you on long-term Aspirin therapy?*
If yes, please explain:
Have you ever had a seizure, or had a brain or other nervous system problem?*
Do you have or live with someone who has cancer, leukemia, HIV/AIDS, or immune system problems?*
In the past 3 months, have you taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or had radiation treatments?*
In the past year, have you received a blood transfusion or blood products, or have been given a medicine called immune (gamma) globulin or an antiviral drugs?*
Have you received any vaccinations in the past 4 weeks?*
Do you get lightheaded or pass out when around needles, receiving shots, or giving blood?*
Are you nursing, pregnant, or is there a chance you could become pregnant during the next months?
If pregnant, how many weeks?
Are you currently using a birth control method?
Please enter your email if you would like confirmation of your registration:
example@example.com
Should be Empty:

*Platte Purchase Middle School ONLY*

Patient Information

Insurance Information

Private Insurance Information

Authorization and Consent

Screening & Questionnaire

Platte Purchase Middle School ONLY