Flu Clinic_Central Middle School

Bear Care: Flu Clinic at Central Middle School
The Bear Care Clinic is offering flu shots at Central Middle School for students!

Date: Tuesday, October 7

Time: 12:30 - 3:30 pm

Student will get their flu vaccine, and we will return them to class in about five (5) minutes!

If the appointment times below do not work for you, please contact us to schedule an appointment in our clinic.

(651) 444-6750

BearCare@RiseUpHealthClinics.org

Students under the age of 18 require parent/guardian consent for health services. Students 18 years and older may complete this form themselves.
Choose a vaccine appointment time. Please call us if you cannot find an available appointment time.*
Patient Information
Patient's Name*

First NameLast Name
Patient's birthdate*

MonthDayYear
Date
Clinic staff use only

Billing Information

Our mission is to provide accessible, affordable care to youth. All children are able to receive health care services in the clinic regardless of their ability to pay or their health insurance status.

You will never be sent to collections for your inability to pay a clinic bill.

What you need to know:
1. Health insurance will be billed after your child’s visit. The clinic has contracts with the following: Blue Cross Blue Shield, Cigna, HealthPartners, Medica, Medicaid, UCare, UMR, and UnitedHealthcare.
2. If you choose not to use your health insurance (commercial plans only) for the clinic visit, you will be billed at the self-pay rate. You will need to sign a waiver in order to bypass submitting the claim to your insurance. Please see the Good Faith Estimate for the cost of services in the clinic available on our website and through our online scheduling link.
3. If you do not have health insurance, you will be billed at the self-pay rate (with the exception of vaccine administration costs). Please see the Good Faith Estimate for the cost of services in the clinic available on our website and through our online scheduling link.
4. If your insurance does not contract with us, you will be financially responsible for any balance not covered by your insurance. There are options for payment. You may:
  - Request a superbill that you can submit to your insurance, OR
  - Elect not to use insurance and be billed at the self-pay rate
Rise Up Health Clinics will issue bills for the health care provided at the clinic and at mobile vaccine clinics.

You may receive a Rise Up Health Clinics bill for a variety of reasons. For example:
- You may have a copay, coinsurance, or deductible
- You may not have health insurance, or we may not have your current insurance information on file
- The service you received may not be covered by your insurance
- You may have received care outside of your provider
- You may not have obtained a required referral from your primary care provider
You are responsible for contacting your insurance company with any questions about any denied charges or out-of-pocket amounts that you owe.

How the billing works:

You will receive one bill from the clinic for the amount that you owe following your child’s clinic visit.

If you are financially able, please pay the bill within 30 days of the date the bill was issued.

If you have any challenges paying your bill, you have options.
- Contact Billing@RiseUpHealthClinics.org for payment options. OR
- If you are unable to pay, your bill will be covered by the Rise Up Health Clinics Health Equity Fund.
Important: Rise Up Health Clinics will never initiate collection actions for any unpaid bills.

Your child can continue to receive care with us regardless of your ability to pay.

Self-Pay Good Faith Estimates - click on the link to view

Preventive (Well) Visit
Sick Visit
Sports Physical Visit
I have read and understand the billing practices listed above. I understand the patient will receive health services regardless of the ability to pay or health insurance status.*

Yes
Billing options: select one*

Bill my insurance: I have health insurance and understand the clinic will bill my insurance.No insurance: I do not have health insurance. I can still receive health services and will receive a self-pay bill.Do not bill my insurance: I have health insurance and choose not to use it for this clinic or am out of network. I understand I will be billed at the self-pay rate.
I acknowledge that this billing consent will remain in effect for one year; or, until the student reaches 18 or completes their high school career; or until changes by me (parent/guardian) are made in writing.

Yes

Insurance information

Please bring your insurance card to the appointment. Note -- if you have given your insurance information to the school district, we do NOT have that information.
Please upload a photo of the FRONT side of your insurance card.

Cancelof
Please upload a photo of the BACK side of your insurance card.

Cancelof
Insurance Provider (for example, BCBS, HealthPartners, UCare)*
Group Number*
Policy Number*
Date Policy Effective From
Policy Holder's Name*
Policy Holder's Birthdate*

Consent for Health Services

By signing this form, I agree to the following:
- I authorize Rise Up Health Clinics (which operates the Bear Care Clinic) and its staff to provide necessary examinations, treatments, procedures, and care as deemed appropriate by the healthcare providers.
- I have the right to refuse or discontinue treatment or care at any time. However, I acknowledge that doing so may have potential risks or consequences, which your healthcare provider will explain.
- If I have any questions about the care provided, I will ask the healthcare provider.
- I consent to receive communications from the clinic, including appointment reminders, follow-up calls, and billing inquiries.
- Rise Up Health Clinics may use student health records to evaluate the quality of care and program effectiveness.
- The patient's school may give class schedule and immunization information to Rise Up Health Clinics only when necessary to provide patient care.
  Rise Up Health Clinics may share immunization information only with the patient's school.
- Immunization information may be shared through the Minnesota Immunization Information Connection (MIIC) with healthcare providers, schools, health departments, and others authorized under law to receive it.
- If receiving communicable disease testing, I acknowledge that the results are required by law to be sent to the Minnesota Department of Health for reporting.
I acknowledge that this consent will remain in effect for one year; or, until the student reaches 18 or completes their high school career; or until changes by me (parent/guardian) are made in writing.*

Yes
I consent that the patient can now make their own appointments and receive care with Rise Up Health Clinics as described above.*

YesNo
Patient Information

The Notice of Privacy Practices and the Patients’ Rights and Responsibilities have been made available to me via the link in this statement and on the clinic website.

https://www.riseuphealthclinics.org/patientinformation
By checking the box below, I acknowledge I have received access to the Notice of Privacy Practices and Patients' Rights and Responsibilities.*

Yes
By signing my name below, I consent to all the above information in this form.*

Powered by Jotform SignClear
Should be Empty:

	No	Yes
Has the patient had a flu vaccine in the past?
Has the patient ever had a serious reaction to any vaccine in the past?
Does the patient have an egg allergy?
Does the patient have any other serious allergies?
Does the patient have a history of wheezing or asthma?
Does the patient live with or have close contact with a person whose immune system is severely compromised and is in protective isolation (for example, cancer, chemotherapy, bone marrow or organ transplant
Does the patient have any long-term health issues or take any medications that weaken the immune system? Please write-in below.
Is the patient pregnant or is there a chance the patient will be come pregnant in the next month?
Has the patient received any vaccines in the past four weeks?

Bear Care: Flu Clinic at Central Middle School

Patient Information

Contact Information

Insurance information