JHCHC School-Based Registration Form

JHCHC School Based Registration Form
Dear Concerned Parent:

Jackson-Hinds Comprehensive Health Center will be providing Early Periodic Screening, Diagnosis and Treatment (EPSDT).

Medical and Dental Services for children and adolescents are offered through our School-Based clinics.

Services include the following:

·       Complete Physical Assessments, Wellness Exams, & Sports physicals

·       Vision Screening

·       Hearing Screening

·       Dental Assessment, Treatment, and Referral

·       Developmental Assessments, Evaluations, and Referral for Treatment

·       Parent and Child Health Education

·       Referral Services
*

Yes, I would like my child to be assessed and treated by Jackson-Hinds.No, I would not like my child to be assessed and treated by Jackson-Hinds.
Name of School*
Patient Name*

First NameMiddle NameLast NameSuffix
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patients Social Security Number*
Home Phone Number*

Area CodePhone Number
Cell Phone Number *

Area CodePhone Number
Work Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender Identity*

MaleFemaleTransgender Male (Female to Male)Transgender Female (Male to Female)Choose Not To Disclose
Race*

Black /African-AmericanWhiteHispanic/LatinoOther
Language*

EnglishSpanishOther
How does your child learn best:*

VerballyWritten MaterialDemonstration
Do you need an interpreter?*
Parent Contact Information*

First NameLast Name
Relationship to Student*
Parent Contact DOB:*

MonthDayYear
Date
Parent Social Security Number*
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
Emergency Contact Relationship to Student*
Additional Contact Number*

Area CodePhone Number
Name of Insurance and Policy Number*
Upload a copy of your Insurance Card Here:

Browse Files

Cancelof
Name and Address of Pharmacy*
Health History: Does anyone in your child’s family have the following: (Check which applies)*

Heart AttackHeart DiseaseHigh Blood PressureStrokeCancerDiabetesSudden DeathSickle Cell AnemiaNervous/Mental ProblemsKidney DiseaseSeizures DisorderArthritisNONE
Child's History: Does your child have the following: (Check which applies)*

NoneChicken PoxAsthmaCommunicable DiseaseMeningitis/EncephalitisTonsillitisHigh Blood PressureHeart Disease/Heart MurmurRespiratory DiseaseKidney DiseaseThyroid DiseaseSeizures (fits/convulsions)Major InjuriesBehavior ProblemsSpeech ProblemsDiabetesBirth DefectsSickle Cell DiseaseSickle Cell TraitEating ProblemsAllergy to Novocain or Dental Anesthesia
FOOD OR DRUG ALLERGY; LIST:*
List any medications your child is taking*
*All physicals in the schools are unclothed, appropriately draped with clinic gown and with a chaperone present. Do you consent to an unclothed exam?*

YesNoNo, Prefer clothed exam only
Lead Poisoning Risk Assessment. Answer ONLY IF YOUR CHILD IS 6 YEARS OLD OR YOUNGER. Check each box for YES or check NONE (if the answer is NO for all).

Does your child live or regularly visit a house or building built before 1960? (Including a daycare center, preschool, the home of babysitter or relative, Or friend’s house)Does this house or building have chipping or peeling paint?Is this house or building being, or has it recently been renovated or remodeled?Does your child have a brother, sister, housemate, or playmate being monitored or treated for lead poisoning?Does your child live with or come in frequent contact with an adult whose job involves exposure to lead, such as pottery, ceramics etc....Does your child live near an active lead smelter, battery recycling plant, or other industry likely to release lead?Do you give your child any folk remedies that might contain lead?Does your child live near a heavily traveled highway where soil / land/ dirt may be contaminated with lead? (Are you aware of any lead contamination in your water supply from outdated plumbing?NONE
PLEASE INDICATE YOUR CURRENT LIVING ARRANGEMENTS:*

LIST ALL PERSONS LIVING IN HOUSEHOLD BELOW*

	RELATIONSHIP TO THE PATIENT	AGE	INCOME
PATIENT NAME
NAME
NAME
NAME
NAME
NAME
TOTAL YEARLY INCOME

GENERAL CONSENT FOR INSURANCE, DIAGNOSIS, AND TREATMENT

I, the patient or parent / guarantor, hereby authorize any holder of information about me or any information needed for settlement of claims to be released to Medicaid, Medicare, or Insurance Provider. I understand approved claims will be deducted from my allocated benefits whether they were rendered in one our clinics or mobile health family.

I request that all health insurance benefit payments be made on my behalf to Jackson-Hinds Comprehensive Health Center. Having registered with JHCHC, I, the undersigned patient or responsible person, understand that this registration form is valid and services will continue as long as I or my child is enrolled in this school or until I decide to opt-out by sending a written notice to discontinue services.

My signature is my authorization to bill on my behalf. My signature also serves as authorization for service and treatment. I may provide a written notice to dismiss this authorization to Jackson-Hinds at any time.
By electronically signing your signature, you are agreeing that you have read and understood the above and consent to submit your application electronically.
PATIENT/PARENT/GUARDIAN SIGNATURE*

Clear
Todays Date*

MonthDayYear
Date
Should be Empty:

JHCHC School Based Registration Form