JHCHC School-Based Registration Form

JHCHC School Based Registration Form
Dear Parents and Guardians:

Welcome to Jackson-Hinds Comprehensive Health Center!
We look forward to working with you to provide the best healthcare services for your child and your family. Jackson-Hinds Comprehensive Health Center (JHCHC) provides a comprehensive continuum of health and social services to meet the needs of our clients. Our mission is to provide quality comprehensive primary and preventive health care and social services to the communities we serve. At JHCHC, we strive to continually exceed the expectations of every patient and customer regarding service, effort, and professional standards.

JHCHC has partnered with your school district to provide school-based health services in several schools. As part of our school-based health services, Jackson-Hinds Comprehensive Health Center provides Early Periodic Screening, Diagnostic, and Treatment Services (EPSDT), medical services, and dental services for children and adolescents through our School-Based clinics and mobile units. Screenings include the following services:
- Complete Physical Assessments (including sports physicals)
- Vision and Hearing Screenings; Wellness screening labs (as indicated for age)
- Dental Assessments, Treatment, and Referrals
- Developmental and Behavioral Screenings and Evaluations and Depression Screenings (age specific)
- Parent and Child Health Education
- Referral Services
Please browse our website a www.jackson-hinds.com to learn about our innovative outreach and delivery of healthcare to our community and to look at our health care services and programs. You will be introduced to some of our outstanding professionals that make up our team of experts, talented staff, and dedicated board of directors. Your child’s healthcare needs are important to us.

Thank you for allowing JHCHC to service your healthcare needs and to be a part of your healthcare team.
Student's Legal Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Patients Social Security Number*
Mothers's Maiden Name: *
Student's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Physical Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Okay to leave a voicemail?

YesNo
Cell Phone Number *

Area CodePhone Number
Okay to leave a voicemail?

YesNo
Work Number*

Area CodePhone Number
Okay to leave a voicemail?

YesNo
Email*
example@example.com
Would you like to sign up for the Patient Portal?

YesNo
Communication Preference (Check all that apply):

MailEmailPatient PortalPrimary Phone
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
Emergency Contact Relationship to Student*
Student's Preferred Language*

EnglishOtherSpanish
Name, Address, and Phone of Pharmacy*
Student's Marital Status*

MarriedDivorceSingleOther
Race*

Black /African-AmericanWhiteHispanic/LatinoOther
Ethnicity*

Hispanic or LatinoUnknownNon Hispanic or LatinaOtherDecline to specify
Gender*

MaleFemale
Name of School*
School Grade*
Parent or Legal Guardian's Income

0 - $14,580$14,581 - $19,720$19,721 - $24,860$24,861 - 30,000$30,001 - $35,140$35,141 - $40, 280$40,281 - $45,420$45,421 - $50,560$50,561 - $99,999
How many people live in your house (**ALL FAMILY MEMBERS OVER THE AGE OF 21 LISTED ABOVE MUST PRESENT INCOME OR A NOTARIZED LETTER STATING HE/SHE HAS NO INCOME AND LIVE WITH YOU FREE OF CHARGE**)*
Insurance Information: What Insurance Coverage Do You Have (Please check all that apply)*

MedicaidDentalMedicareUninsuredPrivate Health Insurance
Name of Insurance and Policy Number*
Upload a copy of your Insurance Card Here:

Browse Files

Cancelof
Parent or Guardian Information*

First NameLast Name
Parent or Guardian Phone Number*

Area CodePhone Number
Parent or Guardian Social Security Number
Parent or Guardian DOB:*

MonthDayYear
Date
Parent or Guardian Consent*

Yes, I would like my child to be assessed and treated by Jackson-HindsNo, I would not like my child to be assessed and treated by Jackson-Hinds
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
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 exam?*

YesNo
Family 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
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 (JHCHC).

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. 1 may provide a written notice to dismiss this authorization to Jackson-Hinds at any time. I understand that Jackson-Hinds Comprehensive Health Center will be providing Early Periodic Screening, Diagnostic, and Treatment Services (EPSDT), Medical Services, and Dental Services for children and adolescents through our School-Based clinics. Screenings include the following services:
- Complete Physical Assessments (including sports physicals)
- Vision and Hearing Screenings; Wellness screening labs (as indicated for age)
- Dental Assessments, Treatment, and Referrals
- Developmental and Behavioral Screenings and Evaluations and Depression Screenings (age specified)
- Parent and Child Health Education
By electronically signing your signature, you are agreeing that you have read and understood the above and consent to submit your application electronically.
Type Parent/Guardian Name: *
PARENT/GUARDIAN SIGNATURE*

Clear
Todays Date*

MonthDayYear
Date
Should be Empty:

JHCHC School Based Registration Form