FAMILY & MULTIPLE CHILDREN REGISTRATION FORM
Parent/ Guardian Information
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Consent for Services
I consent my child to participate MVCHS School-Based Health Center as follows:
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Yes, I give permission for my child to receive SBHC services; which may include medical, behavioral health, case management and/or dental care and for SBHC staff to access my child’s class schedule (for appointment purposes only) and to ask and receive information from the school nurse about my student’s health history. This includes permission for the SBHC staff to consult with and provide information and records to other health care, mental health providers, dental providers including school health professionals, and for purposes of program evaluation and quality assurance. A copy of the HIPAA Notice of Privacy Practices is available upon request. I have been given a copy of the handout “What You Need to Know about Telehealth” and I understand that some SBHC services may be provided through telehealth.
Decline Services
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No, I DO NOT give permission for my child to receive SBHC services**New Mexico law does not require parental consent for some treatment and services under statues; § 24-1-13.1 NMSA 1978, § 24-1-9 NMSA 1978, § 24-8-5 NMSA 1978, §24-10-2 NMSA 1978, §32A-6A-14, 15 NMSA 1978, §24-7A-6.2 NMSA 1978
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Student Name(s)
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Student Name(s)
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Insurance Cards and Account Responsibility
Name of Person Responsible for Account(s)
Signature of Individual responsible for Account(s)
Insurance Card(s)
Patient Right and Responsibilities
You have the RIGHT to: • Be treated with dignity and respect. • The right to efficient and equal service, regardless of your race, sex, religion, ethnic background, education, social class, physical or mental handicap, or economic status. • Be seen in a timely manner. Your time is valuable. • Ask questions about your appointment, health care, treatment plan, or other concerns you may have about your care at the clinic. • Be informed about the staff treating you, including their names and titles. • Friendly, affordable family health care. We provide health care for all members of our community regardless of income, insurance, or ability to pay. If your income falls within the guidelines, regardless of insurance, you may qualify for our sliding fee scale which is based on your income. • High quality health care that meets current medical and social standards. Our medical providers are trained in the current standards of family practice medicine and are able to meet the challenges of a diverse population with varying medical needs. • Confidentiality: Read and ask questions about our Notice of Privacy Practices that has been given to you along with this form. Notice of Privacy Practices describes how your medical information will be used and disclosed for purposes of treatment, payment, and other health care operations. • Receive services in a language you understand. • Select your provider and expect reasonable continuity of care. Patients of MVCHS have the right to switch providers within the organization without repercussion. • Express concerns and complaints without fear of reprisal. Patient complaints can be made verbally, in writing, or by email. An investigation will be completed by MVCHS and the patient will be notified of any action taken by phone, email, or a letter. • Participate in Patient Centered Medical Home Care. • MVCHS patients have the right to appoint a designated person to obtain medical information when it is medically inadvisable to give such information to the patient. You have the RESPONSIBILITY to: • Treat our staff with courtesy and respect. (Failure to do so could result in dismissal from care at MVCHS). • Keep your appointments. If you cannot come to your scheduled appointment please call us at least one hour in advance to cancel. • Arrive for your appointment on time. Please plan to arrive 10 to 15 minutes before your scheduled appointment. • Provide complete and accurate information to the best of his/her ability about his/her health, any medications, including over-the-counter products and dietary supplements, and any allergies or sensitivities. • Follow the treatment plan prescribed by your provider and participate in your care. • Let our receptionist know if you move, change your name or phone number, or have a change of insurance coverage. • Bring your Medicare, Medicaid, or other medical/dental insurance card to each visit. • Bring proof of your income if you wish to qualify for our Sliding Fee Scale. You may use any one of the following to verify your income: last month’s check stubs; last year’s 1040 tax form; a copy of an unemployment check; or a copy of Social Security benefits. • Accept personal financial responsibility for any charges not covered by insurance and pay your bill for clinic services promptly. • Ask questions about your treatment plan or other health care issues that you do not fully understand. • Let us know if we are not meeting your expectations.
About Our Notice of Privacy Practices
We are committed to protecting your personal health information in compliance with the law. The attached Notice of Privacy Practices states: - Our obligation under the law with respect to your personal health information. -How we may use and disclose the heath information that we keep about you. -Your right relating to your personal health information. -Our rights to change our Notice of Privacy Practices. -How to file a complaint if you believe your privacy rights to be violated. -The conditions that apply to uses and disclosures not described in this notice. -The person to contact for further information about our privacy practices.
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