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)
Full legal name (of person who will receive services)(Required)
MM slash DD slash YYYY
Address(Required)
Assigned Sex at Birth(Required)

Gender Identity(Required)
Race(Required)
Ethnicity(Required)

Parent/Guardian Information (if applicable)

Parent/Guardian Name
Address (if different from dependent)

Household Information

Insurance Information

Does the person receiving services have insurance (Medicaid/Husky)?(Required)
Does the person receiving services have Private/Commercial Insurance? If yes, please fill out information below.(Required)
Is there secondary insurance?(Required)

Communication Agreement

I agree to communications regarding care in the following forms (check all that apply)(Required)
If you agree to voicemail being left, please select for which phone(s):
Has the person receiving services seen this dentist/group for 1+ year(s)?(Required)

Emergency Contact

Name

Medical History and Allergies

MM slash DD slash YYYY
Does the client have any medical and/or behavioral health condition(s)?(Required)
Does the client take any medications (including over the counter)?(Required)
Does the client have any allergies?(Required)
Does the patient have an Epi-Pen (or similar prescription) at school or work?(Required)
Has the client ever been hospitalized overnight?(Required)
Has the client had any surgery in the past?(Required)
By signing below, I understand and acknowledge I have read and understand this consent:(Required)
RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION(Required)
CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES(Required)
AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION(Required)
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)
GRIEVANCE PROCEDURE(Required)
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.
MM slash DD slash YYYY
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.
MM slash DD slash YYYY