School-Based Health Services Enrollment Packet

School-Based Health Services Enrollment Packet
School Based Health - Student Registration Form

Please complete the information below about your student. You will need to complete a new form for each student you want to enroll. If the student is 18, they will need to complete and sign these forms themselves.
Student's First & Last Name

First NameLast Name
Birth Gender
Social Security Number
Ex. 123-45-6789
Student Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearMonth - Day - Year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Student's Current School District
Student's Current Building
Student's Current Grade
Student's Current School ID #
Religion
Preferred Language
Race - Check all that apply
Ethnicity
Select all that apply

Student Insurance Information

Please complete the insurance information about your student.
Medicaid Managed Care Plans - Check one below, if applicable
Please enter your Managed Care ID
Primary Medical Insurance
Dental Insurance
Vision Insurance
Please upload pictures of your insurance cards, if available.

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Parent/Guardian Registration

Please enter the parent/guardian information for the student you are enrolling.
Parent/Guardian First & Last Name

First NameLast Name
Birth Gender
Social Security Number
Ex. 123-45-6789
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Please select your relationship to the patient:
Religion
Marital Status
Race - Check all that apply
Ethnicity
Preferred Language
Tax Filing Status
Select all that apply
Please upload Photo ID of Parent/Guardian.

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Minor Consent to Treat & Acknowledgement

Discount Program & Paying for Care

I understand that to see if I can get a discount, I may need to show proof of income. This could be pay stubs, a W-2, or a letter from my job. The health center may ask for more information before giving a discount.

I agree to tell the health center if my family size or income changes. I understand that giving false information can mean that I may not qualify for a discount anymore. I know I must update this information every year.

I understand how the Sliding Fee Discount Program works and agree to follow the rules. Any discount I get applies only to services at Primary Health Solutions. It does not cover appointments from outside places, like other health center. If I do not qualify for a discount or choose to pay full price, I may get a bill.

Privacy Notice

I understand my health information is private and protected by law. It may be used to:
- Provide medical care
- Get payment from insurance
- Run health center operations
I confirm I received a copy of the Notice of Privacy Practices that explains this.

Permission for Care – Minor Patients (Under 18 years old)

I am the parent or legal guardian of the child listed above. I give permission for Primary Health Solutions staff to see and treat my child for medical, vision, and dental care.

When my child is not using School Based Health Services, I will try to go with my child to each visit. If I cannot go, I give permission for the person(s) listed below to go with my child.

This person may:
- Bring my child to the visit
- Complete registration paperwork
- Give health history information
- Make medical or dental decisions for my child
- Sign for shots, blood tests, or other needed care for my child
I understand that only a parent or legal guardian may update address, phone number, insurance, or financial information.

Important Things I Understand
- The staff may talk about my child’s health with the person I send. If there is anything I do not want to share, I must bring my child myself.
- If my child needs another visit, an appointment will be made. A parent or guardian may be asked to come to that visit.
- Some forms may not be completed until medical problems are addressed with a parent or guardian present.
- Medicine refills depend on coming to appointments and sharing health information. Refills may not be given if visits are missed.
- The provider may choose not to give shots, tests, or treatments if they do not have enough information to safely care for my child.
- I can change or cancel this permission at any time by writing to Primary Health Solutions. Changes will not affect care already given.
Sharing Information

I understand I can choose which family members or others can receive information about care. This does not allow copies of medical records. This permission stays in place until I cancel it in writing. An identifier may be required to confirm permission.
Please list any person(s) who you agree to share information with and/or who can approve care for your child.
Please select your relationship to the patient:
Signature of Patient or Responsible Party

Rows	Yes	No	Explain
Stroke
Chicken Pox Disease
Dizziness, fainting, or passing out
History of Guillain-Barré Syndrome:
Development problems:
Asthma:
Heart problem:
Sickle cell disease:
Immune system problem (please explain):
Clotting disorder (please explain):
Other blood disorder (please explain):
Type 1 diabetes:
Type 2 diabetes:
Pre-diabetes:
Other endocrine disorder (please explain):
Psychological or mood problem (please explain)
Seizures (epilepsy):
Date of last seizure:
Other brain or nervous system problem (please explain):
Surgery or admission to the hospital in the last yr:
Cystic fibrosis:
Other lung or breathing problem (please explain):
Liver disease:
Other GI or stomach problem (please explain):
Kidney disease:
Other bladder or urinary problem (please explain):
Pregnant (girls only):
Other problems or concerns (please explain):

Rows	Yes	No
For children less than 9, has the child ever received 2 or more doses of the flu vaccine before July 1, 2017? (if unsure, check “No”)
Does the child live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (such as an isolation room of a bone marrow transplant unit)?
Has the child received MMR (Measles, Mumps, Rubella), Varicella, Yellow Fever, Oral Polio or Flumist influenza vaccine in the last 30 days?
In the past year, has the child received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?
In the past 3 months, has the child taken medications that affect the immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritism Crohn’s disease, or psoriasis; or had radiation treatments?
History of serious vaccine reaction? If yes, which vaccine and explain:

School-Based Health Services Enrollment Packet

School Based Health - Student Registration Form

Student Insurance Information

Consent for Health Services & Treatment

Please check which services you wish for your child to participate in

Parent/Guardian Registration

Discount Program Application

Minor Consent to Treat & Acknowledgement

Discount Program & Paying for Care

Privacy Notice

Permission for Care – Minor Patients (Under 18 years old)

Important Things I Understand

Sharing Information

School Based Health - Student Health History