BEAU CHENE HIGH SCHOOL - SCHOOL BASED HEALTH CARE CONSENT FORM

SOUTHWEST LA PRIMARY HEALTH CARE CENTER, INC CENTER, INC.

SCHOOL BASED HEALTH CENTER

Registration and Consent for Services 2024-2025
Patient Information
STUDENT'S FULL NAME
SOC SEC NO
AGE
DATE OF BIRTH

MonthDayYear
Date
STREET NO ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE NO
Please enter a valid phone number.Format: (000) 000-0000.
DAYTIME PHONE NO
Please enter a valid phone number.Format: (000) 000-0000.
CELL PHONE NO
Please enter a valid phone number.Format: (000) 000-0000.
MARITAL STATUS

Unmarried/SingleMarriedDivorcedSeparatedWidowedOther
EMPLOYMENT STATUS

EmployedSelf EmployedRetiredUnemployed
GENDER

MaleFemaleLGBTQ
EMAIL ADDRESS
example@example.com
Household Members
NAME
AGE
INCOME
NAME
AGE
INCOME
NAME
AGE
INCOME
NAME
AGE
INCOME
Responsible Party / Guarantor Information
NAME
RELATIONSHIP TO PATIENT
Street No Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
RESPONSIBLE PARTY PHONE NO
Please enter a valid phone number.Format: (000) 000-0000.
RESPONSIBLE PARTY WORK NO
Please enter a valid phone number.Format: (000) 000-0000.
EMPLOYER
IN CASE OF EMERGENCY - NOTIFY
NAME
EMERGENCY CONTACT PHONE NO
Format: (000) 000-0000.
EMERGENCY CONTACT RELATIONSHIP
HOUSE HOLD INCOME

(UNINSURED & INSURED MUST PRESENT PROOF OF HOUSEHOLD INCOME)
DAILY
WEEKLY
BI-WEEKLY
MONTHLY
ANNUAL
NUMBER OF MEMBERS IN HOUSEHOLD
UNINSURED: Are you Interested in Applying for Insurance?

YesNo
INSURANCE INFORMATION
MEDICARE NO
MEDICAID NO
INSURANCE COMPANY
Select Insurance Type

PPONon-PPO
CO-PAY
INSURED'S NAME
NAME ON INSURED'S INSURANCE CARD
RELATIONSHIP TO PATIENT
INSURED'S ID NO
INSURED'S GROUP NO
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS VALID AND CORRECT TO THE BEST OF MY KNOWLEDGE
SIGNATURE OF RESPONSIBLE PARTY*
DATE*

MonthDayYear
Date
Check which one applies:

Student is UninsuredStudent has MedicaidStudent has Private Insurance
Release of Information for Payment:

This consent to release information authorizes Southwest LA Primary Health Care Center, Inc to release to any third-party payer indicated to be responsible for payment for this period of treatment. Release of information from my child's health record, or any other information, to verify eligibility and confirm benefits, and secure payment of charges, both during and after the visit. Assignment of Insurance Benefits: I hereby authorize payment directly to Southwest LA Primary Health Care Center, Inc of insurance benefits otherwise payable to me including medical and surgical benefits, not to exceed the reasonable and customary charge for these services rendered by said facility. I authorize the refund of overpaid insurance benefits in accordance with my insurance policy conditions whereby coverage is subject to a coordination of benefits clause. Medicaid Patient Certification: I certify that the information given by me in applying for payment under Medicaid guidelines and Title XIX of the Social Security Act is correct and request that payment of authorized benefits be made on my child's behalf.

Validity:

This authorization is valid for the length of time necessary to process claims for incurred charges. This consent to treatment and care shall remain effective until student departs from the school, unless sooner revoked in writing and delivered to Southwest LA Primary Health Care Center, Inc's School Based Health Center. I understand by signing this document that I authorize my child to receive services offered by the Health Center, including diagnosis, treatment, and counseling services. *I understand that I must give written consent before my child is vaccinated at school. * I understand that I may revoke this consent at any time. * I understand that I may decline any services either by verbal or written request to the staff at the Health Center. *I understand this consent is voluntary and valid for the entire time my child is enrolled in Sunset Middle School, provided I give up-to-date medical insurance and registration information each school year or as needed. By signing this statement, I confirm that I have received, read, and understand the following documents. 1. Registration and Consent for Service Forms. 2. Parents & Students Rights and Responsibilities
Signature of Parent or Legal Representative*
Date*

MonthDayYear
Date
Signature of Witness
Date

MonthDayYear
Date
Student's Insurance ID Number
Primary Insurance
Secondary Insurance
Name of Policyholder
Relationship to Student
Insurance Company Address
Insurance Phone Number
Format: (000) 000-0000.
ID Number Policy Number
Group Number
Employer
Employer Address
Form Completed by
Date

MonthDayYear
Date
Do you consider your child to be in good health?

YesNo
If No - Please Explain
Has your child had any surgeries?

YesNo
List all surgeries the child has had:
Has your child ever been hospitalized?

YesNo
If Yes Explain
Is your child allergic to any medicine, drugs, insects?

YesNo
Explain any allergies to medicines, drugs, or insects here:
Who is your child's doctor?
If no doctor, check here

None
Date of last complete exam

MonthDayYear
Date
Who is the child's dentist?
When was the student's last dental exam?

MonthDayYear
Date
When was the student's last vision exam?

MonthDayYear
Date
(Select any that apply) MY CHILD:

Never had an eye examWears glassesWears contactsWears both
Has your child had the chicken pox disease?

YesNo
If yes, at what age?
If no, has your child had the shot for chicken pox?

YesNo
Name of Preferred Pharmacy
Location of Preferred Pharmacy
Preferred Pharmacy (phone number)
Format: (000) 000-0000.
List of Current Medications with dosage / instructions:
Student's Current and Past Health History

(Select all that apply)
Does your child have now, or has your child ever had any of the following:

Chronic or recurrent skin problems (acne, eczema)Frequent headachesConvulsions, seizures or neurological problemsProblems with eyes or visionDental decay or cavitiesBirth defects / Congenital cataracts / RetinoblastomaFrequent ear infectionsVision or hearing problemsNasal allergiesSnoring or sleep problemsThyroid or other endocrine problemsAsthmaHeart conditionsStomach aches or constipation requiring MD visitsBladder infections, kidney disease
Mark here ONLY IF YOU DO NOT KNOW whether your child has ever had any of the following:

Chronic or recurrent skin problems (acne, eczema)Frequent headachesConvulsions, seizures or neurological problemsProblems with eyes or visionDental decay or cavitiesBirth defects / Congenital cataracts / RetinoblastomaFrequent ear infectionsVision or hearing problemsNasal allergiesSnoring or sleep problemsThyroid or other endocrine problemsAsthma, lung problems, bronchitis, or pneumoniaHeart conditionsStomach aches or constipation requiring MD visitsBladder infections, kidney disease
Does your child have now, or has your child ever had any of the following::

Diabetes, Metabolic or Genetic conditionsAnemia or sickle cellADHD/anxiety/mood problems and depressionHistory of alcohol or drug useHistory of serious injuries/fractures/concussionsHistory of family violence or abuseDevelopmental delay or disabilitiesImmune problems or HIVCancerTuberculosisBleeding problems, blood transfusionsChemotherapyOrgan transplantGIRLS ONLY - Problems with periods
Age at first period
Mark here ONLY IF YOU DO NOT KNOW whether your child has ever had any of the following:

Diabetes, Metabolic or Genetic conditionsAnemia or sickle cellADHD/anxiety/mood problems and depressionHistory of alcohol or drug useHistory of serious injuries/fractures/concussionsHistory of family violence or abuseDevelopmental delay or disabilitiesImmune problems or HIVCancerTuberculosisBleeding problems, blood transfusionsChemotherapyOrgan transplantGIRLS ONLY - Problems with periods
Mark if any family members (parents, grandparents, sister's, brother's) have had the following and write in who

Childhood hearing lossNasal AllergiesAsthmaTuberculosisHigh blood pressure, heart attack, strokeHigh cholesterol, takes meds for high cholesterolAnemia, sickle cellBleeding disorderDental decayCancer (before age 55)
WHO had this disease/condition?
List each family member who had the condition
Mark if any family members (parents, grandparents, sister's, brother's) have had the following and write in who

Liver DiseaseKidney DiseaseDiabetes (before age 55)Lung problemsImmune problems, HIV, or AIDSEpilepsy or convulsionsAlcohol abuse/drug abuseMental illness/depressionObesityDevelopmental disability
WHO had this disease/condition?
List each family member who had the condition
Signature of Parent*
Date Signed*

MonthDayYear
Date
Witness Signature
Sender
Should be Empty:

Patient Information

Household Members

Responsible Party / Guarantor Information

IN CASE OF EMERGENCY - NOTIFY

HOUSE HOLD INCOME

INSURANCE INFORMATION

Student's Current and Past Health History