Partnership Community Health Center Student Athlete Sports Physical Registration

Thank you for registering for the Partnership Community Health Center Sports Physical Event.

Please complete this form so that we can verify insurance, determine eligibility for financial assistance, and prepare for your student's sports physical.

Priority scheduling may be available for students who:

Have Wisconsin Medicaid (ForwardHealth/Badgercare Plus)
Don't have insurance and qualify for our Sliding Fee Discunt Program.

Parent/Guardian Email address

example@example.com

Which school is your student attending?

Student Name

Student's Date of Birth

MonthDayYear

Grade

Student's Gender

Other

Parent/Guardian Name

Parent/Guardian Date of Birth:

Parent/Guardian Home Address

Parent/Guardian's Phone Number

Student's Address

Preferred Contact

Does your student currently have health insurance?

If your Student has Wisconsin Medicaid (i.e. BadgerCare Plus or FowardHeatlth), please provide the Member ID:

If your student has commercial (private) health insurance, please provide: Insurance Company, Plan Name, Member ID, Group Number and the Policyholder's Name:

File Upload- Please upload the front and back of your student's Health Insurance Cards.

Does your student have a primary care provider?

If Yes, please list the provider's name:

Has your student had already had a sports physical in the last 12 months?

If yes, please provide date of physical

MonthDayYear

Would you like information on becoming a patient at Partnership Community Health Center?

Would you like someone to contact you about:

Consent

By checking the box, I certify I am the parent/legal guardian of the minor named above, or otherwise legally authorized to consent to their medical care. I consent to Partnership Community Health Center providing a sports physical and any routine services reasonably necessary to complete this examination. I authorize Partnership Community Health Center to submit claims to the patient's applicable health insurance and authorize payment of benefits directly to Partnership Community Health Center. I understand that I may be financially responsible for services not covered by insurance, subject to applicable clinic policies and financial assistance programs.

Consent

By checking the box, I authorize Partnership Community Health Center to release the student's completed sports physical/athletic clearance form, including the provider's determination of whether the student is cleared, cleared with restrictions, or not cleared to participate in sports, to the student's school and/or athletic department for the purpose of determining athletic participation eligibility. I understand that this authorization is voluntary and that refusing to authorize this disclosure will not affect the student's ability to receive health care services from Partnership Community Health Center,

Electronic Signature (Type your Full Legal Name)

Comments or Questions: