Mobile Health and Dental Clinics

Mobile Health and Dental Clinics

REGISTRATION, CONSENT FOR SERVICES & DISCLOSURE OF Personal Health Information
Services Available

Primary Care Services:
1. Well Child Care and Early and Periodic, Diagnostic and Treatment (EPSDT) Screening and Exam
2. Comprehensive Physical Exams and Sports Physicals
3. Vision Screening
4. Hearing Screening
5. Health Education and Risk Reduction Counseling
6. Sexually Transmitted Disease (STD) Testing

Illness / Injury Care:
1. Minor Injury assessment, treatment and follow-up
2. Acute Illness assessment, treatment, follow-up and/or referral

Chronic Conditions Care:
May include asthma, high blood pressure, obesity, allergies, skin conditions, etc.
1. Exam, diagnosis, and treatment of a new condition
2. Maintenance & follow-up of existing conditions

Immunizations:
1. Screening and assessment using Michigan Care Improvement Registry (MCIR)
2. Administration of immunizations (with parent permission and consent only)

Dental and Oral Health:
1. CLEANING: The benefits include healthy gum tissue, elimination of odors & stains. After cleaning teeth and gums may be sensitive.
2. FLUORIDE TREATMENT: Fluoride varnish is painted on teeth to prevent tooth decay delivering a safe and effective dose of fluoride.
3. X-RAYS: Are needed to complete a diagnosis. Without x-rays the dentist may be unable to diagnose dental disease.
4. SEALANTS: Sealants help prevent decay on the chewing surface of a tooth.
5. LOCAL ANESTHETICS: Local pain medication is used to avoid pain during dental treatment and procedures. Possible complications include extended numbness, nerve damage, bruising, the child could bite his tongue, lips or cheek. In rare occasions possible side effects may include all those related to general anesthesia, including allergic reactions up to an including death.
6. FILLINGS: To restore areas of cavities. Anytime a tooth is repaired for any reason, there is always irritation in the area of the tooth, which may result in sensitivity of the tooth and in some cases you may require more treatment such as a root canal or removal of the tooth.
7. PULPOTOMY IN PRIMARY (BABY) TEETH: Is a root canal for a baby tooth with cavities in the nerve area.
8. STAINLESS STEEL CROWNS: A preformed crown is placed over the tooth when it is too damaged to hold a filling.
9. EXTRACTIONS: Coronal remnants or abscessed primary teeth. Parent will be contacted prior to this service
Childs Name*

First NameLast Name
Gender
DOB*

MonthDayYear
Ethnicity (optional)
School Name
Type Name of School Please
Grade
Parent/Guardian Name*

First NameLast Name
Parent Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone

Area CodePhone Number
Alt. Phone

Area CodePhone Number
Do you have a current medical provider (Doctor's Office)?

YesNo
Medical Provider Name and Contact Information
Has a Dentist seen the child in the past 12 months:

YesNo
Dentist Name and Contact Information
Insurance Type

MedicaidOther
ID #
Name of Insurance Holder:
Employer:
Group #
Contract #
Health History: Check each condition that applies to your child.

AsthmaArtificial JointTuberculosis/emphysemaDiabetesAIDS/HIVHepatitis/Liver diseaseBehavioral ProblemsBleeding disordersCerebral PalsyCongenital Heart Disease/ DefectHearing loss/difficultyHeart Attack or StrokeHeart Surgery/problemsKidney/ Bladder DiseaseMouth/tooth painNausea/vomitingPacemaker/Implanted DevicesPregnant, NursingPsychiatric/Psychological CareRadiation/Chemo TreatmentsVisionEpilepsy/seizures
Current Medications-List all:
Allergies-List all:
Surgeries-List all:
By signing I confirm that I am the parent/legal guardian of the child named above. I confirm I have the legal authority to give consent for his/her medical and dental care. I know I can ask any questions about treatments my child may receive. I give the Family Health Center to:

• Perform procedures and treatment that are deemed appropriate and to seek further emergency assistance, if needed.
• I am authorizing FHC to administer age appropriate immunizations for medical patients to ensure my child remains up to date,
• Provide dental care for my child including: preventive services such as cleaning, sealants and fluoride, restorative services; and simple extractions as needed.
• Release information regarding these services for purposes of receiving insurance payment.
• I understand I am responsible for charges not paid by insurance and will be billed on a sliding scale based on my ability to pay.
• Exchange medical information, lab results and immunization records with the child’s personal doctor/ health care provider for the purpose of continuity of coordination of health care
• My physician may perform an HIV and AIDS test if a health facility employee is exposed to my child’s blood or other bodily fluids.
• Share this child’s immunization records with the school/immunization providers.
• Allow academic dental or medical students under direct supervision of a licensed dental/medical professional to provide services.
• Provide health education information
• Share information with staff of Communities In Schools of Kalamazoo (CIS), Kalamazoo Public Schools (KPS), Kalamazoo Regional Educational Service Agency (KRESA) , Head Start, Great Start Collaborative, KCReady 4, Family Health Center, and Kalamazoo Health and Community Services.
• In case of a minor child, the authorization is valid for any adult who accompanies my child to FHC and will remain in effect until revoked in writing.
in effect until revoked in writing.

Please indicate the following care options you would like your child to receive. If both services are needed check "Medical and Dental Care" option, then sign your name in the signature box below.
Care Options

Medical CareDental CareMedical and Dental Care
Parent Signature*

Clear
Date*

MonthDayYear

As parent/guardian I understand that treatment may be obtained at the patient’s dental home/medical home rather than at the school clinic/mobile dental facility and that obtaining duplicate services at the Clinic/mobile dental facility may affect benefits that the patient received from the medical/dental insurance.

In an emergency, It is okay (I authorize) for an adult to seek medical help for my child. If I have questions about any emergency related to my child’s medical or dental services, I may call the Mobile Manager 269-349-2641 Ext. 690

1. Family Health Center Notice of Privacy Practices: The Notice of Privacy Practices is posted online at http://www.fhckzoo.com under Mobile Health Clinic information. This is available in Spanish and English. If you would like to have a hard copy please call at 269-349-2641.

2. Authorization for Use and Disclosure of PHI. I allow the use and sharing of my child’s identifiable health information as described below. I understand that this section is voluntary and will not cause my child to be ineligible for services at the FHC and KHCS mobile clinics. If the individual I list (authorize) to receive the information is not a health plan or health care provider I know that the released information may no longer be protected by federal privacy regulations.
Family Health Center Services is authorized to receive/release my health information from/to:

First NameLast Name

Specific Information that will be disclosed will include Child Health Registration, Health History, and Child Medical, Dental and Oral Health Records; for the purpose of providing Medical and Dental Care.

This Authorization will be kept on file and will remain in effect since your signature day until the end of the school year. You have the right to have a copy of this form once it is signed. You have the right to cancel this consent or authorization above at any time, in writing. If you cancel it only applies to uses and services after cancelation date. If you would like a copy of this consent for your records please call us at: 269-349-2641

I am legal parent or guardian for my child. I have read and agree to all parts of this form. The Mobile Health Clinic and/or the Mobile Dental Clinic may provide services for my child except the services I listed below:
Service Exemptions
Full Legal Name (Patient or Parent/Guardian if a minor)*
Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear
Child's Name

First NameLast Name
Relationship*
Should be Empty: