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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)
MM slash DD slash YYYY
Address
(Required)
Street Address
(PO Box, Apartment #, etc.)
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is the person receiving services a student in school (preschool to twelve grade)?
(Required)
Yes
No
If the person receiving services is in school, please fill out the information below.
School
(Required)
Bennie Dover Jackson Middle School (New London)
Catherine Kolnaski STEAM Magnet School (Groton)
C.B. Jennings International Elementary Magnet School (New London)
Dr. Charles G. Barnum School (Groton)
Ella T. Grasso Technical School (Groton)
Fitch High School (Groton)
The Friendship School (Waterford)
Gales Ferry School/Juliet W. Long School (Gales Ferry)
Gallup Hill School (Ledyard)
Groton Middle School (Groton)
Ledyard High School (Ledyard)
Ledyard Middle School (Gales Ferry)
Mystic River Magnet School (Groton)
Nathan Hale Arts Magnet School (New London)
New London High School (New London)
Northeast Academy (Groton)
Regional Multicultural Magnet School (New London)
Stonington High School (Pawcatuck)
Stonington Middle School (Stonington)
Thames River Magnet School (Groton)
West Vine Elementary School (Pawcatuck)
Winthrop STEM Magnet Elementary School (New London)
None of the above
Grade
(Required)
Do you also authorize your child to be registered for School-Based Health Center services?
(Required)
Yes
No
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
No
Medicaid #:
(Required)
Name on card:
(Required)
Does the person receiving services have Private/Commercial Insurance? If yes, please fill out information below.
(Required)
Yes
No
Policy Holder Name
(Required)
First
Last
Policy Holder Date of Birth
(Required)
MM slash DD slash YYYY
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Is there secondary insurance?
(Required)
Yes
No
Secondary Policy Holder Name
(Required)
First
Last
Secondary Policy Holder Date of Birth
(Required)
MM slash DD slash YYYY
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
No
Emergency Contact
Name
First
Last
Relationship
Phone Number
Medical History and Allergies
Date of Last Physical?
MM slash DD slash YYYY
Does the client have any medical and/or behavioral health condition(s)?
(Required)
Yes
No
If yes, please list here:
(Required)
Does the client take any medications (including over the counter)?
(Required)
Yes
No
If yes, please list here:
(Required)
Does the client have any allergies?
(Required)
Yes
No
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
No
Has the client ever been hospitalized overnight?
(Required)
Yes
No
Has the client had any surgery in the past?
(Required)
Yes
No
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
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.
Signature of Client/Parent/Legal Guardian/Personal Representative:
Signature Date
MM slash DD slash YYYY