Hale Ola Kino Maika i

Similar documents
ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

School-Based Health Center William Penn High School 713 E. Basin Road New Castle, DE Phone: Fax:

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5.

School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:

School Based Health Consent for Services Grace Community Health Center, Inc.

Client Registration Form

Sage Medical Center New Patient Forms

School Year

School Year

Choptank Community Health System Caroline County School Based Health Centers Healthy Children Are Better Learners MEDICAL

PATIENT REGISTRATION FORM (ecw)

Welcome Baby Prenatal Intake

Social Security Number: Employment Status: Employed Unemployed Address: Student Retired

Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:

PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.

Pediatric Patient History

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

Health Needs Assessment You may also fll this form out online at NHhealthyfamilies.com

PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD

Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self

Columbia Medical Practice- Pediatrics Ken Klebanow M.D. and Associates

Dear Kaniksu Patient,

Patient Name: Last First Middle

Welcome Letter- Orchard School Clinic

California Student Opportunity and Access Program Los Angeles Consortium Fall 2015 High School Scholarship Application

Planned Respite Referral Application

PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip

Adult Health History

Welcome To. School Information:

Dear New Patient, Once again, we would like to thank you for choosing us as your primary health care provider. We look forward to working with you.

2017 Medi-Slim Weight Loss Patient Information Form

NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE

TEMPORARY LECTURER APPLICATION FOR EMPLOYMENT

CORAZON PANES SANCHEZ., M.D., L.L.C.

Additionally, the parent or legal guardian must provide the following documents upon registration of a new student:

Woonsocket Health Hut Handbook

The Home Doctor. Registration Checklist

Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name

107 Commercial Street Mashpee, MA (fax)

APPLICATION TO TRADITIONAL RN TO BSN PROGRAM

APPLICATION INFORMATION

Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801

Fulcrum Orthopaedics Patient Registration Packet

APPLICATION TO RN TO BSN PROGRAM

Crescent Community Clinic Application for Healthcare Services

Lavaca SBHC Providers, Services, Hours, and How to Make an Appointment

Welcome to The Brevard Health Alliance

ADMISSION FORM. Employment Status: Retired Unemployed Employed Full Time Employed Part Time

R. B. KO L A C H A L A M M. D. GENERAL SURGERY

ALFRED ALINGU, MD INTERNAL MEDICINE

Responsible Party (Guarantor) Info. Insurance Information

School-Based Health Center Enrollment Packet

The Providers and Staff of Baptist Medical Group Primary Care- LiveOak BAPTISTMEDICALGROUP.ORG. Primary Care - Live Oak.

Kent State University Health Services. Medical History Form

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

INSURANCE INFORMATION

Summer College Prep Program July 7 th, 2014 July 25 th, 2014

Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:

2017 VolunTeen Application. Fort Belvoir Community Hospital

PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.

INFORMATION CERTIFICATION

Pediatric New Patient Intake Form

Welcome to St. Bonaventure University. We are glad you re here!

Date: Patient/Parent/Legal Guardian Signature CHCP Form #PCS104 (rev. 6/16 per UDS)

ADMISSION FORM. Employment Status: Retired Unemployed Employed Full Time Employed Part Time

Fulcrum Orthopaedics Patient Registration Packet

Hope Academy of Public Service GENERAL STUDENT INFORMATION

CALIFORNIA STATE UNIVERSITY, STANISLAUS School Nursing Application to the Pre-licensure Nursing Program

GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP

Buchanan YMCA New Traditions Elementary School

If you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study.

Last Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone

Division of Peer-Based Services 9-Month Internship Program

APPLICATION. Name (Last, First, MI): Address: City, State, & Zip Code: Home Telephone: Cell Telephone: Date of Birth: / /

New Substitute Paraprofessional or Secretary Fingerprint-Based Criminal Background Check Procedures

Please print clearly and complete fully. Incomplete forms may delay the intake process. Thank you. Client Name: (First) (Middle Initial) (Last)

HEALTH HISTORY QUESTIONNAIRE

LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W

The process has been designed to be user friendly and involves a few simple steps.

Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL

Pediatric New Patient Form

Julia Julz Abate, Respite Administrator or

Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country

BONITA UNIFIED SCHOOL DISTRICT

VETERINARY & BIOMEDICAL SCIENCES SUMMER CAMP-2018 REGISTRATION FORM

Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone. Date of Birth SS#

PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE #

HIDD 101 HOSPITAL INPATIENT AND DISCHARGE DATA IN NEW MEXICO

INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF CPYB 5-WEEK SUMMER BALLET PROGRAM S HEALTH FORM PACKAGE

UNIVERSAL INTAKE FORM

Bachelor of Science Nursing (RN to BSN)

PRIMARY HEALTH SOLUTIONS SCHOOL BASED HEALTH CENTER ENROLLMENT PACKET

W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c

PATIENT INFORMATION FORM

UNIVERSITY OF NORTH DAKOTA PHYSICIAN ASSISTANT PROGRAM

INFORMED CONSENT FOR TREATMENT

Transcription:

We ve teamed up to make it easier for students to access healthcare in their school! Together, we are your School-Based Health Center! Waianae High School (WHS) is proud to partner with Waianae Coast Comprehensive Health Center (WCCHC) to provide a School-Based Health Center (SBHC) at WHS. WCCHC gives students an opportunity to be seen by a licensed health care provider without having to miss school. The following 4-page registration form includes a parent/legal guardian-representative consent. STAFF CONTACT INFORMATION AND HOURS Our staff includes licensed health care providers to assist students and we are available to communicate with the parent/legal guardian-representative of each child. We want to know your concerns and be able to keep you updated on your child s health. Feel free to contact us during office hours. SUMMER 2017 Monday Friday June 19 July 7 (8:00 am 12 noon) July 24, 25, 31 & August 1 (8:00 am 1:00 pm) HALE OLA KINO MAIKA I CONTACT INFORMATION 85-251 Farrington Highway 2 nd Floor, Building B Waianae, HI 96792 PH. (808) 697-3520 Fax (808) 697-3521 HOURS OF OPERATION FALL SEMESTER Monday, Wednesday, Friday 7:45 AM 2:45 PM Tuesday and Thursday 7:45 AM 1:45 PM August 7, 2017 May 31, 2018 CLOSED: July 8 23, 26, 27, 28 August 2, 3, 4 NOTE: Clinic hours subject to school calendar. Making it easy for students to receive health care right in their own school! We accept most health insurance plans Convenient one-stop medical care at your school Walk-ins are welcome Keeps students in school Eliminates parents time away from work Flexible appointments are available Full-time board-licensed medical staff

Waianae Coast Comprehensive Health Center & Waianae High School SCHOOL-BASED HEALTH CENTER REGISTRATION and CONSENT FORM STUDENT Last Name First Name Middle Initial Male Female Date of Birth (mm/dd/yyyy) Gender Address (Street) City, State Zip Code Mobile Phone Home Phone Email RACE (please check ONE): Native Hawaiian (Hawaiian/Part Hawaiian) American Indian/Alaska Native Asian (Japanese, Chinese, Vietnamese, Laotian, Filipino, etc.) Black/African American Hispanic/Latino (Puerto Rican, Mexican, Guatemalan, etc.) Other Pacific Islander (Tongan, Samoan, Micronesian, etc.) White/Caucasian (Including Portuguese) STUDENT HEALTH HISTORY CITIZENSHIP (please check ONE): U.S. Citizen by Birth Naturalized Citizen Immigrant Permanent/Alien ETHNICITY (please check ONE): Hispanic or Latino Not Hispanic or Latino Allergies to food or medications Disabilities CURRENT MEDICATIONS: Medication/Supplement Dosage Medication/Supplement Dosage CHECK ANY OF THE FOLLOWING THAT APPLY TO THE STUDENT S HEALTH HISTORY: ADHD Anemia Asthma Bleeding Disorder Cancer Chronic Sinusitis Depression Diabetes Epilepsy Eating Disorders Esophageal Reflux Heart Disease Heart Murmur Hearing/Vision Growth Problems Hepatitis High Cholesterol HIV + /AIDS Kidney Disease Latex Allergy Liver Disease Pregnancy (Teens) Seasonal Allergy Seizure Disorder Sickle Cell Disease Sexually Transmitted Diseases (STDs) Stomach Problems Weight Problems Other Doctor/Pediatrician Phone Number Pharmacy of Choice Phone Number ALTERNATE CONTACT INFORMATION (if parent/legal guardian-representative is unavailable): Print Name Work/Home Phone Mobile Phone Email

PARENT OR LEGAL GUARDIAN-REPRESENTATIVE Yes No Father s Name: Last Name First Name Middle Initial Lives with you Father s Contact Information: Yes No Mother s Name: Last Name First Name Middle Initial Lives with you Mother s Contact Information: STUDENT MEDICAL INSURANCE (Please complete the information below) Name of Health Insurance Plan Policy Number Group Number Guarantor: Last Name First Name Middle Initial Address City State Zip Code Guarantor Date of Birth Guarantor s Contact Information: Guarantor Employer FINANCIAL INFORMATION (Complete this section only if you do not have medical insurance) Number of People in Household: Gross Monthly Family Income: $ Are you homeless? Yes No If yes, please check one: Shelter Transitional Doubling Up Street

PARENT/LEGAL GUARDIAN-REPRESENTATIVE CONSENT FOR STUDENT TO RECEIVE SERVICES AT THE SCHOOL-BASED HEALTH CENTER I, the parent/legal guardian-representative of said student, give consent for the student to receive all services at Waianae High School s School- Based Health Center including medical (e.g. vaccinations, physical exams, evaluation of injuries, and referrals) and behavioral health services (e.g. screenings, diagnoses, therapy, and referrals). I understand that youth 14 and above may consent to their own outpatient behavioral health services. SBHC staff will encourage every student to involve his/her parents/legal guardian-representatives in health care decisions. I understand that I may receive more information about minor consent services. I understand that the student s healthcare information is confidential, but that in certain instances, law allows or requires use and disclosure to others including if (1) you or the student authorizes the release of information, (2) a court so orders, (3) the student presents a danger to the student or others, or (4) child or elder abuse/neglect is suspected. I understand that SBHC is operated by WCCHC in cooperation with Waianae High School. It is not part of, or directly operated by Waianae High school. I understand that SBHC is operated by WCCHC and certain records about the student and the student s treatment shall be kept in written and computerized form and may be reviewed by other providers at WCCHC as needed. I understand that the student may be seen by a trainee/student who is identified as such and that all services provided will be supervised by a licensed provider. I have the right to refuse services by a trainee/student. I understand that no student will be denied access to health services due to inability to pay. As in any health center, there may be a charge depending on the service provided. When available, insurance will be billed. I understand that SBHC may release information regarding treatment to third party payers for billings purposes. I agree to pay my portion of the student s costs, if any, associated with services received. I am the parent/legal guardian-representative of the student. I understand that if guardianship or representation changes, a new consent must be signed by the legal guardian-representative. I also understand that by providing an alternative contact, if I cannot be reached, medical information regarding the student may be shared between the medical provider and the alternative contact. I understand that this consent form is valid for the student s entire enrollment at Waianae High School or until I provide SBHC staff with written directions otherwise. CONSENT TO ADMINISTER MEDICATION I agree to my child receiving any medication(s) required for his/her care at the School-Based Health Center. I understand that medications, or a generic equivalent, will only be administered by a Medical Assistant or Registered Nurse per a Doctor s or Nurse Practitioner s order. My child may receive all medications offered at the School-Based Health Center, except for the following: Preferred Pharmacy (Name & Location): CONSENT TO RELEASE INFORMATION By signing below, I give authorization for Waianae Coast Comprehensive Health Center to release to Waianae High School copies and/or updates of my child s immunization and/or Sports Physical Exam s/he received at the SBHC.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires all physicians and health are facilities to provide patients with a notice describing how an individual s medical information may be used and disclosed, and how a patient may obtain access to their personal health information. A copy of this policy is located at the School-Based Health Center or can be obtained from our sponsoring center s website, http://www.wcchc.com/home/privacy. You must sign below, indicating that you have received notification on how to obtain a copy of our HIPAA policies prior to the student receiving services. Return completed registration form (4 pages) to WHS School-Based Health Center 2nd Floor, Teacher s Lounge, Building B

2024 © careersdocbox.com Privacy Policy | Terms of Service | Feedback