COPLIN HEALTH SYSTEMS SBH Registration Form

COPLIN HEALTH SYSTEMS

School-based Health Enrollment Form
Patient Full Name
Patient's Date of Birth

MonthDayYear
Date
Patient's Sex

MaleFemaleUnknown
Student Social Security Number
Patient/Student's Preferred Name
Patient Address

Street Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Home Phone Number of Student
Cell Phone Number of Student
Students School Name
School Phone Number
Student's Grade Level
Communication Preference (for automated appointment reminders, etc)

VoiceTextEmail
Student's Email (there is a place for parents email below):

Does not have emailWill not discloseThere is another reason the email is not being providedStudent's email is:
Preferred Provider to see at Coplin Health Systems
Primary Care Provider
Patient was referred to Coplin Health Systems by Individual or Doctor
Preferred Language

EnglishSpanishOther
Translater needed

NoYes
Responsible Party Name (Responsible for Bill)
Responsible Party Birthdate

MonthDayYear
Date
Responsible party Address

Mailing Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Responsible Party Phone Number
Responsible Party Cell Phone Number
Please enter a valid phone number.
Responsible Party Work Phone Number
Please enter a valid phone number.
Responsible Party's Relationship to Patient
Father's Name
Father's email
example@example.com
Father's Home Phone Number
Please enter a valid phone number.
Father's Work Number
Please enter a valid phone number.
Father's Cell Phone Number
Please enter a valid phone number.
Mother's Name
Mother's Maiden Name
Mother's email
example@example.com
Mother's Home Phone Number
Please enter a valid phone number.
Mother's Work Phone Number
Please enter a valid phone number.
Mother's Celll Phone Number
Please enter a valid phone number.
Guardian's Name
Guardian's email
example@example.com
Guardian's Home Phone Number
Please enter a valid phone number.
Guardian's Work Phone Number
Please enter a valid phone number.
Guardian's Cell Phone Number
Please enter a valid phone number.
EMERGENCY /ALTERNATE CONTACT INFORMATION: I understand that by providing an alternate contact if I cannot be reached, medical information regarding the above-named child will be shared between the medical provider and the alternative contact (including all relevant information with exception to psychiatric/mental health, alcohol/drugs, and HIV/AIDS information
Name of Emergency Contact
Relationship of Emergency Contact
Address of Emgerency Contact
May we leave a message with the emergency contact?

YesNo
Home Phone Number of Emergency Contact
Please enter a valid phone number.
Work Phone Number of Emergency Contact
Please enter a valid phone number.
Cell Phone Number of Emergency Contact
Please enter a valid phone number.
I Authorize Coplin Health Systems to share the patient's personal health information (PHI) with the named persons below.
Name of Individual with Rights to PHI
Date of Birth of Individual with Rights to PHI

MonthDayYear
Date
Relationship to Patient of Individual with Rights to PHI
Phone Number of Individual with Rights to PHI
Types of Records That Can Be Shared with the Above Individual

MedicalDentalBillingSchedulingBehavioral HealthSUDsHIV/AIDsAll Record Types
Name of Second Individual with Rights to PHI
Date of Birth of Second Individual with Rights to PHI

MonthDayYear
Date
Relationship to Patient of Second Individual with Rights to PHI
Phone Number of Second Individual with Rights to PHI
Types of Records That Can Be Shared with the Above Individual

MedicalDentalBillingSchedulingBehavioral HealthSUDsHIV/AIDsAll Record Types
Insurance Information
Name of Insured Parent/Guardian
Date of Birth of Card Holder

MonthDayYear
Date
SSN of Card Holder
Address if Different From Child
Place of Employment of Card Holder
Name of Insurance Company
Insurance ID Number
Insurance Group Number
Secondary Health Insurance:
Name of Insured Parent/Guardian for Secondary Insurance
Date of Birth of Card Holder for Secondary Insurance

MonthDayYear
Date
SSN of Card Holder for Secondary Insurance
Address if Different From Child for Secondary Insurance
Place of Employment of Card Holder for Secondary Insurnace
Name of Insurance Company for Secondary Insurnace
ID Number of Secondary Insurnace
Group Number of Secondary Insurance
Dental Insurance
Name of Insured Parent/Guardian for Dental Insurance
Date of Birth of Card Holder for Dental Insurnace

MonthDayYear
Date
SSN of Card Holder for Dental Insurance
Address if Different From Child of Dental Insurnace Card Holder
Place of Employment of Dental Insurnace Card Holder
Name of Insurance Company for Dental Insurance
ID Number for Dental Insurance
Group Number for Dental Insurance
Secondary Dental Insurance
Name of Insured Parent/Guardian for Secondary Dental Insurance
Date of Birth of Card Holder for Secondary Dental Insurance

MonthDayYear
Date
SSN of Card Holder for Secondary Dental Insurance
Address if Different from Child for Secondary Dental Insurance
Place of Employment of Card Holder for Secondary Dental Insurance
Name of Insurance Company for Secondary Dental Insurance
ID Number for Secondary Dental Insurance
Group Number for Secondary Dental Insurance
Student has no health insurnace

Student does not have any health insurnace coverageI would like to request a sliding fee applicationI would like assistance from Coplin Health Systems to obtain insurance
I agree to the following:

I agree to allow Coplin Health Systems access to the patient's prescription historyI agree to leave my credit/debit card on fileI agree to have nursing and/or medical students present during the care of the patient
Current Medications & Health information
Medication Name 1
Dose (mg) of Medication 1
Directions for Medication 1
Medication Name 2
Dose (mg) of Medication 2
Directions for Medication 2
Medication Name 3
Dose (mg) of Medication 3
Directions for Medication 3
Medication Name 4
Dose (mg) of Medication 4
Directions for Medication 4
Date of last wellchild exam

MonthDayYear
Date
If your child has not seen a doctor within the last year, would you like your child to have a well-child exam at our wellness center?

YesNo
If we need to call in a prescription which pharmacy would you like us to call?
The portable dental unit visits schools twice a year (fall and spring) for dental exams, fluoride treatments, cleaning, and sealants. Please note if your child has an appointment and the forms are not signed and returned for each dental visit, the appointment will be canceled. If your child is going to another dentist and does not need these services, please mark "no" below. Services utilized through the Portable Dental Unit will be billed to your insurance. If you do not have coverage, the sliding fee scale will provide a discount for your child to be seen by the dentist. To see if you qualify for this reduced rate, you must complete the income section of the enrollment, and complete a sliding fee discount application. If your child already has a dentist, he/she does not qualify for this program. Your insurance will not cover the fees of both your regular dentist and this program.
Name of Current Dentist
Date of last dental exam

MonthDayYear
Date
If your child has not seen a dentist in the last year, would you like your child to have a dental cleaning at our Wellness Center?

YesNo
If yes, do you want your child to have dental sealants on the same day as cleaning?

YesNo
Coplin Health Systems is a Federally Qualified Health Center, and we offer special pricing and discounted costs to our patients. To ensure that we continue to receive this designation and funding, we must report specific information about the population that we serve. We ask that you assist us by completing the following information.
How many people are currently living in your household?
What is your estimated household monthly net income?
Household Status

Own my homeRentLive with someoneIn shelterTransitionalHomeless
Gender

FemaleMaleTransgender MaleTransgender FemaleChoose to not discloseOther
Sexually Orientation

StraightLesbian/GayBisexualOtherDon't KnowChoose to not disclose
Military Status

Not a veteranVeteranActive Service
Disability Status: Do you have a disability as identified by the Americans with Disabilities Act

YesNo
Race

WhiteBlackAmerican Indian/Alaskan NativeNative Hawaiian/Pacific IslanderAsianNative AmericanOther
Ethnicity

Not Hispanic/LatinoHispanic/LatinoDecline to SpecifyOther
Telehealth Informed Consent

This section must be completed for any Telehealth Serivces
1. I understand that SBHC medical and behavioral health services may be completed via telehealth in place of face-to-face visits. I understand these encounters will not be the same as a direct patient/health care provider visit because the provider will not be in the same room. Instead, two-way simultaneous audio-visual technology will be utilized.

2. I understand that I/my dependent has the right to refuse to participate in any telehealth encounter at any time or to end it at any point during the encounter. I understand that if I/my dependent do(es) not wish to participate in a telehealth encounter, other healthcare arrangements will need to be made. I further understand that the provider may not be able to accommodate an in-person visit, and there may be a delay in care if an in-person visit is chosen.

3. I understand that the provider can discontinue the telehealth visit if he or she believes that this technology does not meet the standard of care necessary to address the concerns. If that happens, I understand an appointment for an in-person visit with a provider will need made, or I should seek care at the closest emergency department if I believe that symptoms warrant that level of care.

4. I understand how the technology will be used to conduct any telehealth visit with this practice. I also understand that, with this technology, there is a risk of interruption and technical difficulties.

5. I understand that the identity of everybody who will be in the room with my healthcare provider will be disclosed during any telehealth encounter and that those people will be present only because the provider has determined that their presence is necessary to assist in medical treatment according to the applicable standard of medical care.

6. I understand that I will be responsible for any co-pays and coinsurance that apply to the telehealth visits

7. I understand that the provider may use this technology to take a picture to be used for my care. The provider will inform me before this is done. These photographs will be treated and protected just as any other protected health information. Outside of this, video and photographs are not recorded nor stored from telehealth visits.

8. I understand that the same laws that protect the confidentiality of personal information also apply to telehealth. In all but a few rare situations, my confidentiality is protected by state law and by the rules of licensing boards. The most common cases in which confidentiality is not protected include, but are not limited to: Child and vulnerable adult abuse expressed imminent harm to oneself or others, and as part of legal proceedings where information is required by court of law.

9. I understand that Coplin Health Systems has an integrated Behavioral Health program, and patient records are shared between Behavioral Health and Medical, and are only viewed as allowable by law, with all records kept confidential and protected.

10. I understand that care via telehealth is not the same as in-person services, and therefore the results, despite every effort of the provider, may not be the same. I understand that I may benefit from telehealth services, but results cannot be guaranteed or assured.

11. I understand that telehealth services are considered outpatient services and are not intended to substitute for emergency or crisis services.

12. This consent will remain valid for twelve (12) months from the date of signature.

I understand the above notice and consent for the patient named above to receive telehealth services, as needed, for Medical services(initial) and/or Behavioral Health services(initial)
Initial for consent to Behavioral Health Services via Telehealth
Initial for consent to Medical Services via Telehealth
General Informed Consent
I, the legal parent/guardian, with my signature on this form, give consent for my child to receive services at Coplin Health Systems. I have read, understand, and agree to all the above as I have selected. The information is correct to the best of my knowledge. I understand that this consent form will be good for one year or until I provide Coplin Health Systems with written directions otherwise, whichever is shorter. By signing the consent form, I am giving Coplin Health Systems, the school nurse, and my child's regular doctor (if applicable) permission to communicate and share medical information regarding this applicant's medical condition on an as-needed basis with the understanding that this information will continue to be treated confidentially. No student will be denied access to health care services due to the inability to pay. As in any health center, there may be a charge depending on the service provided. I agree that when available, my insurance or Medicaid can be billed. The health center may release information regarding treatment to third-party payors for billing purposes. I understand that I am financially responsible for any balance. I understand and agree to the financial policy. Confidentiality between the student, parents, and the health center is assured. I understand how to obtain a copy of the Notice of Privacy Practices from a Patient Representative, viewed on the lobby wall, or on the website at www.coplinhealth.com The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur for my treatment, payment of bills, or in the performance of Coplin Health Systems' care operational and other purposes that are permitted and requiredby law. It also describes my rights to access and control my protected health care information. I understand and agree for my information will be shared with the WV and OH Health Information Networks, CommonWell, CareQuality and Surescripts; if I want to remove this access, I understand that I will need to provide a written statement to opt out. I agree that by providing contact information, Coplin Health Systems may contact me or those listed above. I understand that if guardianship changes, the legal guardian must sign a new consent. The documentation for guardianship and custody must be provided with the registration form and anytime there are updates.

If you selected to have your child receive cleanings and/or sealants, signing this enrollment form will provide consent for him/her to participate in the portable dental services and confirms that your child does not already have a dentist.

Coplin Health Systems is a Federally Qualified Health Center (FQHC), and as such we qualify for special pricing and discounted costs for our patients.
Printed Name of Patient or Responsible Party
Signature of Patient or Responsible Party

Clear
Date

MonthDayYear
Date
Should be Empty:

COPLIN HEALTH SYSTEMS

Telehealth Informed Consent

General Informed Consent