Example CBC Enrollment

This form is meant to obtain health information from individuals who are receiving services from Child and Family Agency of Southeastern CT, Inc. (CFA)’s Medical Clinic.

Client Information

Relationship to Person Receiving Services(Required)

I am filling out this information for myself.

I am the parent of a minor receiving services.

I am the legal guardian of a minor receiving services.

Define:(Required)

Full legal name (of person who will receive services)(Required)

First Last

Preferred Name (if any)

Date of Birth(Required)

Address(Required)

Street Address (PO Box, Apartment #, etc.) City State ZIP Code

Is the person receiving services a student in school (preschool to twelve grade)?(Required)

Yes

If the person receiving services is in school, please fill out the information below.

School(Required)

Grade(Required)

Do you also authorize your child to be registered for School-Based Health Center services?(Required)

Yes

Assigned Sex at Birth(Required)

Female

Male

Other

Gender Identity(Required)

Male

Female

Transgender Male

Transgender Female

Non-binary

Other/Prefer not to Answer

Race(Required)

Unknown

Prefer not to answer

Black

American Indian

Asian

Pacific Islander

White

Alaskan Native

Other

Ethnicity(Required)

Hispanic

Non-Hispanic

Language(s) Spoken at Home(Required)

Parent/Guardian Information (if applicable)

Parent/Guardian Name

First Last

Address (if different from dependent)

Street Address Address Line 2 City State ZIP Code

Household Information

Number of people in the home

Household Income

Insurance Information

Does the person receiving services have insurance (Medicaid/Husky)?(Required)

Yes

Medicaid #:(Required)

Name on card:(Required)

Does the person receiving services have Private/Commercial Insurance? If yes, please fill out information below.(Required)

Yes

Policy Holder Name(Required)

First Last

Policy Holder Date of Birth(Required)

Name of Medical Insurance(Required)

Member ID#(Required)

Group Number(Required)

Insurance Phone#(Required)

(On back of card)

Policy Holder's Employer(Required)

Address (If different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is there secondary insurance?(Required)

Yes

Secondary Policy Holder Name(Required)

First Last

Secondary Policy Holder Date of Birth(Required)

Secondary Insurance(Required)

Secondary Member ID #(Required)

Secondary Group Number(Required)

Secondary Insurance Phone #(Required)

(On back of card)

Address (If different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Communication Agreement

I agree to communications regarding care in the following forms (check all that apply)(Required)

Home phone

Cell phone

Work phone

Home phone(Required)

Cell phone(Required)

Work phone(Required)

If you agree to voicemail being left, please select for which phone(s):

Home Phone

Cell Phone

Work Phone

Parent/Guardian Email Address

Client Email Address (if over 13 years)

Primary Care Provider Name (if none, write N/A):(Required)

Primary Care Provider Phone

Dentist's Name (if none, write N/A)(Required)

Dentist Phone

Has the person receiving services seen this dentist/group for 1+ year(s)?(Required)

Yes

Emergency Contact

Name

First Last

Relationship

Phone Number

Medical History and Allergies

Date of Last Physical?

Does the client have any medical and/or behavioral health condition(s)?(Required)

Yes

If yes, please list here:(Required)

Does the client take any medications (including over the counter)?(Required)

Yes

If yes, please list here:(Required)

Does the client have any allergies?(Required)

Yes

If yes, please list here (foods, medications, latex, etc.)(Required)

What do the allergic reaction(s) look like?:(Required)

Does the patient have an Epi-Pen (or similar prescription) at school or work?(Required)

Yes

Has the client ever been hospitalized overnight?(Required)

Yes

Has the client had any surgery in the past?(Required)

Yes

By signing below, I understand and acknowledge I have read and understand this consent:(Required)

I give permission for myself/my dependent to obtain routine health services at the CFA Medical Clinic. Insurance will be billed at the time of visit. Sliding scale for payment available for those without medical insurance.

RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required)

I authorize the release of any medical or behavioral health information necessary to process my claim. I also authorize payment of health benefits to CFA for services provided.

CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)

Click here to review the Agency’s Privacy Practices

I understand and acknowledge that I have read and understand this consent and I have received CFA’s Notice of Privacy Practices currently in effect. I understand that information regarding how CFA will use and disclose my information can be found in CFA’s Notice of Privacy Practices. I understand my consent is effective for as long as CFA maintains my protected health information.

AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION(Required)

I give permission to allow CFA to exchange as needed information with my/my dependent’s medical provider in order to effectively care for me/my dependent. I understand that CFA medical and mental health providers may communicate with each other about my dependent’s care if indicated.

I also certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to the client’s health. I will notify the CFA Medical Clinic of any changes to medical information.

MEDICAL HEALTH AND SENSITIVE PERSONAL HEALTH INFORMATION

The Health Information Exchange (HIE) system is a secure computer system that brings your protected health information (PHI) from different healthcare locations into one nationwide electronic health record. The HIE system network provides participating practitioners access to past and present medical and behavioral health information to make better decisions and better coordinate care with your healthcare team. The HIE system takes your privacy and security very seriously. The HIE system does not store any of your health/clinical data and uses end-to-end encryption to help ensure your data is secure. Only those involved in your care can look at your information.

The State of Connecticut participates in the HIE, meaning that medical health information (e.g. immunizations, medications, physical examinations, and psychiatric information, etc.) are shared with other medical providers unless a specific opt-out is received.

Additionally, sensitive PHI is PHI that is "subject to heightened confidentiality requirements in compliance with all federal and state laws as amended from time-to-time (e.g. HIV, substance abuse and mental health records). Clients must specifically authorize disclosures of sensitive PHI.(Required)

I opt-in for Child and Family Agency of Southeastern CT, Inc. (CFA) to share information from and to the HIE.

I opt-in for CFA to only receive documents from the HIE.

I opt-in for CFA to only send documents from the HIE.

I want to opt-out of any medical information and sensitive PHI being sent to other health care providers.

GRIEVANCE PROCEDURE(Required)

Click here to review the Grievance Procedures online.

I have acknowledged reading the Agency’s Grievance Procedure.

By signing below, I understand and acknowledge the following: My sensitive health information will be available to providers using The HIE system. I understand that refusal to sign this authorization form will not affect my right to obtain present and future services. I also understand that I may opt-out of HIE at any time by notifying CFA of the named recipient in writing.

Electronic signature of person authorizing health information exchange(Required)

Today's Date

By signing below, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent.

Signature of Client/Parent/Legal Guardian/Personal Representative:

Signature Date