Welcome Letter- Orchard School Clinic

Transcription

1 Welcome Letter- Orchard School Clinic Dear Parent or Guardian: Orchard School Clinic is a school-based location of RiverStone Health Clinic. This is a collaborative effort between RiverStone Health, Billings Public Schools and Billings Clinic. The goal of the Orchard School Clinic is to improve the health and well-being of the students and their immediate family. Healthy students are more likely to succeed in school. What is Orchard School Clinic? Orchard School Clinic, a school-based clinic, is an extension of RiverStone Health Clinic and is open to students and families of Orchard, Newman, Ponderosa and Washington Elementary Schools and Riverside Middle School. The Clinic is open during the school year Monday-Friday 12 pm- 4 pm. Orchard School Clinic provides routine well child exams with immunizations, school and sports physicals, preventative care, urgent care and behavioral health services. Orchard School Clinic is staffed by physicians, physician assistants, child psychiatrist, nurses and a licensed clinical social worker. The purpose of the Clinic is to provide high quality healthcare in a friendly setting, at a time that is convenient to the student and the family. Orchard School Clinic can be your regular healthcare provider or can support your regular doctor/clinic. Is there a charge for the Clinic s services? Orchard School Clinic accepts Medicare, Medicaid, Healthy Montana Kids and most insurance plans. If you have insurance, we will directly bill your insurance company. You will be responsible for co-pays and unmet deductible amounts. We also have a sliding fee scale that is based on income and family size. How do I enroll in Orchard School Clinic? There an enrollment process that is required before we can provide care to your child. Children cannot be seen in the Clinic without your consent and completion of the enrollment process. Call the Orchard School Clinic at or orchardclinic@riverstonehealth.org to request an enrollment packet. Visit our website RiverStoneHealth.org, under Clinic Locations to find the Orchard School Clinic enrollment materials online. Complete and return the enrollment packet What happens after I enroll? By completing the enrollment process, the student may be seen at Orchard School Clinic. If your student has a primary care provider other than Orchard School Clinic or RiverStone Health, we will contact your primary care provider regarding the services provided. If your child has a Medicaid Passport Provider other than RiverStone Health, we will need to request and receive authorization from the Passport Provider prior to the visit. To schedule an appointment, please call the Orchard School Clinic at

2 Orchard School Clinic Patient Information Form STUDENT INFORMATION Student s Last Name: Mother PARENT/GUARDIAN INFORMATION Student s First Name: Last Name: First Name: Date of Birth: / / Month Day Year Cell Phone # Father Sex: Male Female Grade Ethnicity: Hispanic Black White American Indian Asian/Pacific Islander Other Student Address: City State Zip Code Does the student communicate in a language other than English? No Yes: Language Who is the student s regular doctor? Name: Telephone: Address: Last Name: First Name: Cell Phone # Legal Guardian, If Applicable Last Name: First Name: Relationship of legal guardian to student Grandparent Aunt or Uncle Other: Contact Information for parent or guardian Home Tel: Work Tel: Cell: Additional Emergency Contact Name: Relationship to Student: Home Tel: Work Tel: Cell: INSURANCE INFORMATION Does your child have Medicaid or HMK/CHIP? No Yes: Medicaid ID # Does your child have coverage through your employer or any other type of health insurance? No Yes, Health Plan: PREFERENCES Does your child have a regular dentist? No Yes: Name Preferred Pharmacy: Name: Member ID/Policy Number: Location: Health Insurance Phone: If your child does not have health insurance, would you like a Certified Application Counselor to contact you to enroll into health insurance? Do you wish to apply for our sliding fee scale which is based on income and family size? No Yes No Yes

3 Patient Health Information Orchard School Clinic Name: Date of Birth: / / Do you have ANY ALLERGIES or SENSITIVITIES: Yes No If yes, please list below: Medications: List medicines, birth control pills, herbal supplements or vitamins you take with or without a prescription: Illnesses: Please where you or members of your family (parents, grandparents, siblings) have had the following diseases or problems: Patient Family Who Patient Family Who ADHD High Blood Pressure/Hypertension Alcoholism Kidney/Bladder Problems Anxiety Liver Disease, Hepatitis, Yellow Jaundice Asthma Mumps, Measles, Chicken Pox Bleeding Disorder or Blood Clots Mental Illness Cancer or Tumor Stroke Diabetes Suicide Attempt Domestic Violence Thyroid Disease Drug Abuse Tobacco Use Eczema Emphysema Other Illnesses: Epilepsy/Seizures Eye Problems Glaucoma HIV/AIDS Heart Disease Patient/Guardian Signature Date Revised: 7/27/2015

4 Consent for Treatment/Assignment of Benefits Orchard School Clinic Child s (Patient) Name (Please Print) Parent/Guardian Name (Please Print) Child s Primary Care Doctor I hereby request and authorize RiverStone Health Clinic to assess, evaluate, and provide care and treatment to the patient listed above. I understand that I may be treated by a behavioral health provider as part of my medical care and that these encounters will be a part of the medical record. I understand that a licensed clinical pharmacist may participate in my care and as part of my care team to provide, among other benefits, drug therapy management. (Initial Here) I authorize my health care provider and public health agency to collect and enter immunization records into the Montana Department of Public Health and Human Services confidential Immunization Information System registry. I understand that information in the registry may be released to a public health agency as well as to my health care providers to assist in my medical care and treatment. In addition, childrens immunization information may be released to child care facilities and schools to comply with State immunization requirements. I understand that I can revoke this authorization and have my record removed at any time by contacting my local health department. I authorize RiverStone Health to access my prescription history from outside sources, including but not limited to SureScripts. I further understand that I am responsible for the cost of my care. I understand that RiverStone Health Clinic offers a Sliding Fee Scale based on family income; if I qualify for the Sliding Fee Scale I remain responsible for the remaining balance for my care. I hereby assign any of my health insurance benefits to be paid directly to RiverStone Health Clinic. I hereby authorize the release of medical information related to the payment of those insurance benefits. If the patient listed above is enrolled in the Montana Medicaid Passport program, I authorize RiverStone Health to contact my Passport provider for authorization. Signature: Date: Updated 7/27/2015

5 Authorization to Disclose Health Information Orchard School Clinic I authorize RiverStone Health disclose to School the following protected health information ( protected health information ) of (the Student ), including all of the following unless otherwise indicated below: Information required by law; Conditions which may require emergency treatment; Conditions which limit the Student s daily activities; and Conditions which require the Student to be absent from school. By signing this authorization, I understand that I am authorizing the RiverStone Health to use or disclose the Student s protected health information to Orchard School for the purpose(s) I have identified. I understand I can revoke this Authorization in writing at any time and doing so will stop future use or disclosure of the Student s protected health information; but I understand that RiverStone Health can act on this Authorization until either I revoke my authority in writing or until the expiration date in this authorization. If I want to revoke this Authorization, I will send written notice of revocation to RiverStone Health at 123 South 27 th Street, Billings MT Attn: Medical Records. I understand I can refuse to sign this Authorization and I am signing it of my own free will. I understand that if I should decide to not sign this Authorization there will be no retaliation from RiverStone Health, nor will there be any effect on the Student s treatment or payment for services. I understand I can see and copy my protected health information as described in RiverStone Health s Notice of Privacy Practices. I understand RiverStone Health cannot control any further disclosure of my protected health information by Orchard School after it is disclosed as allowed by this Authorization, and that my protected health information may not be subject to continued protection under federal law once it is received by the recipient. Unless I indicate at an earlier time below, this Authorization expires on the date the Student is no longer enrolled in the Orchard School Clinic or is no longer a student at School. Earlier expiration of Authorization:. I have read and understand the release of protected health information described in this Authorization. My signature indicates my consent to release protected health information as specified. Signature: Parent/Guardian Date: Printed Name of Parent or Guardian: Updated 6/13/16

6 About RiverStone Health s Notice of Privacy Practices In compliance with the law, RiverStone Health is committed to protecting your personal health information. The attached Notice of Privacy Practices states: Our obligations under the law with respect to your personal health information. How we may use and disclose the health information that we keep about you. Your rights 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 have been 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. RiverStone Health is required by the law to give you a copy of this notice and to obtain your written acknowledgement that you have received or declined a copy of this notice. Patient Acknowledgement I,, hereby acknowledge that I have received a copy of the Notice of Privacy Practices. OR I,, hereby decline receipt of a copy of the Notice of Privacy Practice. Patient s Signature Date Signature of Parent or Patient s Representative (if applicable) Date Description of Legal Authority to Act on Behalf of Patient