Lion's Clinic Paperwork

MID-DELTA HEALTH SYSTEMS LION'S CLINIC ENROLLMENT PACKET
We welcome you and your child to be part of our Mid-Delta Health Systems Lion's Clinic. It offers students and faculty access to primary care services. Mid-Delta Health Systems, Inc. (MDHS) is a Federally Qualified Health Center with three service locations in Clarendon, DeWitt, Stuttgart, along with the Lion's Clinic. Parents/Guardians are always welcome at appointments, but are not required to be present as long as THIS PACKET IS FULLY COMPLETED and RETURNED.

How the Mid-Delta Health Systems Lion's Clinic Works: Once the student's completed consents and history are received (which are enclosed in this packet), we can begin caring for your child for approved services. We will attempt to notify you of your child's appointment and contact you by phone providing information on his/her visit. If the parent/guardian has signed consents and is not reachable via phone to discuss the appointment, MDHS will provide a care visit summary to send home to the parent regarding the child's visit.

Already a patient at MDHS: If you are already a patient of MDHS we ask that you still complete this packet because some of the packet information varies from our standard patient packet.

This packet includes:

About our School-Based Health Center

School Based Health Center Enrollment Form

Patient Information Form

Consent to Treat/Telehealth

HIPAA Privacy Information

Notice of Privacy Practices

Health History

Application for Reduced Fees
Parent/Guardian Signature*

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Today's Date*

MonthDayYear
Date

MID-DELTA HEALTH SYSTEMS LION'S CLINIC ENROLLMENT FORM
School District
Campus
Grade
Graduation Year
Student's Name*

First NameMiddle NameLast Name
YES, I would like for my child to receive medical care at the Mid-Delta Health Systems Lion's Clinic. If marking yes, Please continue to complete the remainder of this packet. Services could include treatment for illness or injury, including over the counter medications or necessary prescriptions, well child exams, telehealth appointments, immunizations and emergency services as needed. Please list the best contact number below:
Parent/Guardian

First NameLast Name
Phone Number

Area CodePhone Number
NO, I do not wish for my child to receive medical care at Mid-Delta Health Systems Mobile Clinic. If marking no, you do not have to complete the remainder of this packet. If your child has emergent needs at the school, care will be provided regardless of the selection on the form.
**Please check only one box which best fits your needs:

My child regularly goes to another doctor or clinic for health care. I would like the Mid- Delta Health Systems Lion's Clinic to work with my child's doctor/clinic to keep my child healthy. I give my permission to the Mid-Delta Health Systems Lion's Clinic personnel to release medical records of all treatable visits to the health care provider listed belowMy child does not have a regular doctor or clinic. I would like the Mid-Delta Health Systems Lion's Clinic to provide health care as necessary to keep my child healthy.
Child's Health Care Provider
Parent/Guardian Signature

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Today's Date

MonthDayYear
Date

PATIENT INFORMATION FORM
Student Information
No change from previous year
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Social Security #
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Primary Language
Race
Ethnicity

HispanicNon-Hispanic
Emergency Contact (other than parent)
Name
Phone #

Area CodePhone Number
Relationship to Student
Parent/Guardian Contact Information
Parent/Guardian
Parent/Guardian DOB

MonthDayYear
Date
Parent/Guardian SSN
Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact #

Area CodePhone Number
Health Insurance Information
Insurance Name
Policy Holder's Name
Policy #
Phone # from Insurance Card

Area CodePhone Number
Group # (if any)
If you don't have health insurance or have billing questions, please contact the Mid- Delta Health Systems Mobile Clinic at the number provided with this packet. If there are any changes to insurance after this form is completed, please contact the clinic to update.
Please mark if your child does not have insurance coverage. MDHS will not deny child care due to inability to pay.
Household Information
Income Range for Household (please provide best estimate, exact amounts not required) or select 'choose not to disclose'
Choose not to disclose
Number in Household
Pharmacy Name/Location
Parent/Guardian Signature

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Date

MonthDayYear
Date

CONSENT TO TREAT
MDHS requires that a parent or guardian give specific permission if a minor child will receive treatment when the child is accompanied by someone other than the parent or guardian. When a parent or legal guardian is not immediately available and advanced consent has not been provided, emergency care will not be delayed, but verbal consent and authorization will be required as quickly as possible for treatment. MDHS also realizes you may have family members or significant people whom you may wish your provider speak with regarding your child's healthcare information. Without your written consent, we cannot release any information to anyone except for purposes outlined in the HIPAA privacy act.

The person(s) listed here is/are authorized by me to give consent in person for medical treatment and for the Mid-Delta Health Systems Lion's Clinic to contact about appointment outcomes and other information pertaining to my child. This is in effect until revoked in writing by me. This person may also sign any necessary consents or acknowledgements on my behalf, including responsibility for payment (attempts should be made to contact parent or legal guardian for vaccine administration).
Name
Relationship to Student
Phone Number

Area CodePhone Number
Name
Relationship to Student
Phone Number

Area CodePhone Number
Name
Relationship to Student
Phone Number

Area CodePhone Number
I, First Name Last Name (parent/guardian) grant permission for school personnel to transport and/or accompany the above-named student to MDHS visits. child's school
As with other health related matters, health information cannot be released without consent. Therefore I, First Name Last Name (parent/guardian) also hereby authorize MDHS to release sports physical results to my child's school.
Parent/Guardian Name

First NameLast Name
Name of Child's School
Please read and sign the consent below.
I give consent for my child to receive health care services provided by the staff at the Mid-Delta Health Systems Lion's Clinic. Services could include treatment for illness or injury, including over the counter medications or necessary prescriptions, well child exams, appropriate immunizations, telehealth appointments for medical and behavioral health, and appropriate behavioral evaluations-- unless emergency services are needed. I understand that every effort will be made to contact me prior to any treatment that requires parental consent I WILL NOTIFY THE MID-DELTA HEALTH SYSTEMS LION'S CLINIC IN WRITING IF I WISH TO REMOVE MY CHILD FROM THE HEALTH PROGRAM. In order to provide optimal health care to your child, I understand that it is necessary that the school nurse and designated school personnel be involved in my child's care, including facilitating visits with the Mid-Delta Health Systems Lion's Clinic provider.
Parent/Guardian Signature

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Date

MonthDayYear
Date

HIPAA PRIVACY
Mid-Delta Health Systems is committed to providing security for patient privacy and confidentiality. This organization collects, uses, and discloses personal health information only in conformance with state and federal laws and your personal authorization. Please understand that this may include the collection of other sources of information available, such as medication and prescription history and verification of insurance eligibility.

Mid-Delta Health Systems participates ni programs such as the State Health Alliance for Records Exchange (SHARE), ot share and receive your health information statewide among your doctors, hospitals, labs, radiology centers, and other health care providers through secure, electronic means. With access ot your up-to-date health information, your doctor can provide safer, more effective health care that is tailored to your personal medical needs. If you wish to opt-out, you must ask your health care provider for and complete an Opt-Out Form. You can also opt-out for your minor child (under the age of 18) using the same process.
I would like to receive a copy of Mid-Delta Health Systems' Notice of Privacy Practices.
I authorize Mid-Delta Health Systems' to bill my insurance for services rendered.
Parent/Guardian Signature

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Date

MonthDayYear
Date

STUDENT HEALTH HISTORY
Child's Name

First NameLast Name
DOB

MonthDayYear
Date
Are there any problems that concern you about your child?
Does your child have any allergies (food, medication, environmental)? Please list the allergy and the reaction:
Current medications (include vitamins/fluoride/supplements):
1.
Prescribed by
2.
Prescribed by
3.
Prescribed by
Date of last physical examination

MonthDayYear
Date
By Whom
Date of last dental examination

MonthDayYear
Date
By Whom
Date of last eye examination

MonthDayYear
Date
By Whom
List hospitalizations, illnesses, accidents, broken bones, surgeries, etc. Please include Date and Child's age and explain
Please list any specialist that your child currently sees:
1.
Location
2.
Location
3.
Location
Parent/Guardian Signature

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Date

MonthDayYear
Date

	Yourself	Mother	Father	Grandparents	Sibling	Spouse	Child
AIDS
Alcoholism
Allergies
Alzheimer's
Anemia
Arthritis
Asthma
Birth Defects
Bleeding Disorder
Breast Cancer
Cancer
Colon Cancer
COPD
Depression
Diabetes
Emphysema
Epilepsy
Glaucoma
Heart Attack
Heart Trouble
High Blood Pressure
IBS
Kidney Disease
Liver Disease
Mental Illness
Migraine Headaches
Pneumonia
Prostate Cancer
Sickle Cell Anemia
Stroke
Suicide
Tuberculosis
Ulcers

MID-DELTA HEALTH SYSTEMS LION'S CLINIC ENROLLMENT PACKET

MID-DELTA HEALTH SYSTEMS LION'S CLINIC ENROLLMENT FORM

PATIENT INFORMATION FORM

Student Information

Emergency Contact (other than parent)

Parent/Guardian Contact Information

Health Insurance Information

Household Information

CONSENT TO TREAT

HIPAA PRIVACY

STUDENT HEALTH HISTORY

HEALTH HISTORY (CONTINUED)

PERSONAL AND FAMILY HISTORY

PERSONAL HISTORY (CONTINUED)

Social History

APPLICATION FOR REDUCED FEES