Manitou Campus_Flu and Vaccine Mobile Clinic

Bear Care Clinic: Vaccine Consent for Manitou Campus
The Bear Care Clinic is offering flu shots or school vaccines at the Manitou Campus.

Date: November 3

Time: 12:30 pm - 2:30 pm

Location: in the Manitou Campus building
- Students are welcome to get their vaccines at any time while Bear Care is present (an appointment is not needed).
- After receiving their vaccine(s), we will return them to class or lunch in about five (5) minutes!
- A parent or guardian must complete this form before the student receives a vaccine.
(651) 444-6750

BearCare@RiseUpHealthClinics.org

Students under the age of 18 require parent or legal guardian consent for health services.

Students 18 years and older must complete this form themselves.
Patient Information
Patient's legal name

First NameLast Name
Patient's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Responsible Party: Contact Information
Who is responsible for receiving clinic bills and appointment information?

First NameLast Name
Relationship to patient
Email of person responsible
example@example.com
Phone number of person responsible
Who is scheduling this appointment?

Other
Is the parent/legal guardian with you completing the form? For example, are you translating for the parent/legal guardian or typing in their answers?

Has the patient use the Bear Care Clinic in the past?

Rows	Yes, I have read, understand, and consent.
Patient Responsibility: Health insurance will be billed after the patient’s visit. The clinic has contracts with the following: Blue Cross Blue Shield, Cigna, HealthPartners, Medica, Medicaid, UCare, UMR, and UnitedHealthcare. The patient is responsible for any and all co-payments, deductibles, and coinsurance. Any balances not covered by insurance become the responsibility of the patient. Patients are responsible for contacting their insurance company with any questions about any denied charges or out-of-pocket amounts that they owe.
Services Covered: It is the patient’s responsibility to determine which services are covered by insurance, including but not limited to, sports physicals, well-child checks, and preventative care. If laboratory testing is needed that cannot be completed in the clinic, specimens may be sent to Rise Up Health Clinics’ contracted laboratory for processing. The laboratory may bill the patient or their insurance directly for these services. Any charges for outside laboratory services are the responsibility of the patient or the responsible party. Rise Up Health Clinics does not determine or control the laboratory’s fees, billing practices, or payment rates.
Waiving Health Insurance: If the patient chooses not to use their health insurance (commercial plans only) for the clinic visit, they will be billed at the self-pay rate. They will need to sign a waiver in order to bypass submitting the claim to insurance. Good Faith Estimates will be available for patients, per the Good Faith Estimate policy. Patients who receive insurance through Minnesota Health Care Programs (MHCP) are not eligible to waive insurance.
Contracted Insurance Plans: If the insurance does not contract with RUHC or if all services provided by the clinic are not covered by the patient’s insurance, the patient will be financially responsible for any balance not covered by their insurance.The patient may: (a) Request a superbill that they can submit to insurance, OR (b) Elect not to use insurance and be billed at the self-pay rate
Incorrect Insurance Information: If the insurance information the patient submits to the clinic is incorrect, the patient will be responsible for payment of the visit and submit charges to the correct plan. The patient may: (a) Request a superbill that they can submit to insurance, OR (b) Elect not to use insurance and be billed at the self-pay rate
Uninsured: If the patient does not have health insurance, they will be billed at the self-pay rate.
Clinic Bills: The patient will receive their bill from the clinic for the amount that they owe following the clinic visit. If the patient is financially able, they will pay the bill within 30 days of the date the bill was issued. The clinic will send out bills via email or text weekly for 60 days. If needed, bills may be sent out via mail. Rise Up Health Clinics will issue bills for the health care provided at the clinic and at mobile vaccine clinics.
Receiving Bills: The patient may receive a Rise Up Health Clinics bill for a variety of reasons. For example: (a) The patient may have a copay, coinsurance, or deductible. (b) The patient may not have health insurance, or RUHC may not have the patient’s current insurance information on file. (c) The service the patient received may not be covered by their insurance. (d) The patient may have received care outside of their provider. (e) The patient may not have obtained a required referral from their primary care provider. Clinic bills will be emailed and sent via text. Message and data rates may apply. You may opt out of text messages at any time by emailing Billing@RiseUpHealthClinics.org. Bills will be emailed from pm-practicefusion@practicefusion.com.

Insurance information

Please bring your insurance card to the appointment.
Does the clinic have the patient's most up-to-date insurance 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/Member ID number
Policy effective date
Policyholder's name
Policyholder's date of birth
Policyholder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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.
- 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

Consent

Rows	Yes
I acknowledge that this consent will remain in effect until the end of this school year; or, until the student reaches 18 years; or until changes by me (parent/guardian) are made in writing.
I acknowledge I have received access to the Notice of Privacy Practices and Patients' Rights and Responsibilities.

I consent that the patient may make their own appointments and receive care/treatment with Rise Up Health Clinics as described above.
Write in any other persons who have your permisison to make appointments, attend appointments, or receive information about the patient.
Name of person completing this form (must be parent, legal guardian, or self for 18 years+)

First NameLast Name
By signing my name below, I consent to all the above information in this form.

Is there anything else you want us to know about the patient or appointment?
Should be Empty:

Rows	No	Yes
Has the patient had a flu vaccine in the past?
Has the patient ever had a severe reaction to any vaccine in the past?
Does the patient have any 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 take any medications that weaken the immune system?
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?
Is the patient on asprin or salicylate-containing medication therapy?
Does the patient have a history of Guillain-Barre syndrome?
Does the patient have a history of a cerebral spinal fluid (CSF) communication leak?
Does the patient have a cochlear implant?
Does the patient have any long-term or chronic illnesses?
Has the patient reecived antiviral medications in the past three weeks?
Does the patient have an egg allergy?

Bear Care Clinic: Vaccine Consent for Manitou Campus

Patient Information

Responsible Party: Contact Information

Health Information

Demographics

Race and Ethnicity

Food and Basic Needs

Emergency Contact

Insurance and Paying for Care

Insurance information