SCHOOL BASED HEALTH CENTER (SBHC) CLIENT REGISTRATION

All information on this registration must be completed and signed before a client can receive services from the School Based Health Centers (SBHC) at Child and Family Agency of Southeastern Connecticut, Inc. (CFA).

CLIENT INFORMATION

Name*

Client First Name Client Last Name

Date of Birth*

Address*

Street Address City State ZIP Code

Client School*

Client Grade*

Race

Ethnicity

Language Spoken at Home*

Assigned Sex

Gender Identity

Other, please specify*

Client’s Primary Care Provider (If None, write “None”)*

Referring Organization/Provider (If None, write “None”):

MEDICAL HISTORY

Date of last physical exam:

Does the client have any medical and/or behavioral health conditions?*

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

Does the client have any allergies?*

Has the client ever been hospitalized overnight?*

Has the client had any surgeries in the past?*

EMERGENCY CONTACT

Emergency Contact Name (First & Last):*

First Last

Emergency Contact Phone Number:*

INSURANCE INFORMATION

All insurances will be billed at the time of a visit. For additional information please review CFA’s Financial Agreement. Please provide a copy of the client’s insurance card, if available. If your child needs health insurance, please call 1-877-CT-HUSKY.

Does the client have Medicaid/HUSKY insurance?*

Does the client have private/commercial insurance?*

Medicaid or Member #

Name on card:

Subscriber Name/Responsible Party

Subscriber Birthday*

CONSENT FOR TREATMENT AND SERVICE AGREEMENT

This document records consent for treatment and outlines the conditions under which services are provided by Child and Family Agency of Southeastern Connecticut (CFA).

Client/ Person Receiving Services at CFA*

First Last

Date of Birth*

Address*

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

Person Providing Consent to Treatment (Select one)*

I am 13 years of age or older and am requesting and consenting to receive services. The information above is my own

I am 18 years of age or older and am requesting and consenting to receive services. The information above is my own

I am the parent/legal guardian of a minor requesting/receiving services and have the legal authority to consent to treatment. My information is provided below:

Parent/Legal Guardian Name*

First Last

Relationship to Client (select one):*

Parent/Legal Guardian

Other(specify)

Other(specify):*

Address*

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

SERVICE CONDITIONS AND EXPECTATIONS

By consenting to treatment for myself or the client, I understand that:

CONSENT FOR TREATMENT AND SERVICE AGREEMENT

ACKNOWLEDGEMENT AND SIGNATURES

By signing below, I voluntarily consent (or authorize the named client) to receive services provided by CFA. I acknowledge that I have reviewed, understand, and agree to CFA’s Service Conditions and Expectations as outlined in this document

Client/Person to Receive Services Signature (if 13 years of age or older)

Date

Name

First Last

Signature

Parent/Legal Guardian Signature (if applicable)

Date*

Name*

First Last

Signature*

NOTICE OF PRIVACY PRACTICE

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Click here to review the Notice of Privacy Practices

NOTICE OF PRIVACY PRACTICES FOR SUBSTANCE USE DISORDER TREATMENT INFORMATION

This notice describes how health information related to Substance Use Disorder (SUD) treatment by Child & Family Agency of Southeastern Connecticut, Inc (CFA) may be used and disclosed, your rights with respect to your SUD treatment information and how to file a complaint concerning a violation of the privacy or security of your SUD treatment information, or of your rights concerning your SUD treatment information. You have a right to a copy of this notice, in paper or electronic form, and to discuss it with our Privacy Officer, whose contact information is listed below if you have any questions.

Click here to review the Notice of Privacy Practices for Substance Use Disorder Treatment Information.

Kim Kalajainen Chief Operating Officer & Privacy Officer

Phone: 860-437-4550

Email: [email protected]

Notice of Privacy Practices

I acknowledge that I have been provided with CFA’s Notice of Privacy Practices. I understand that this acknowledgement confirms that I received the Notice of Privacy Practices. It does not mean that I agree with its contents or authorize the use or disclosure of protected health information.

Date

Client/Person to Receive Services Signature (if 13 years of age or older)

First Last

Signature

Date*

Parent/Legal Guardian Signature (if applicable)*

First Last

Signature*

CLIENT RIGHTS AND RESPONSIBILITIES

Clients receiving services from Child and Family Agency of Southeastern Connecticut, Inc., (CFA) or its affiliates, are entitled to certain rights and responsibilities.

Confidentiality

Information regarding a client’s treatment will not be disclosed to anyone outside of CFA without the appropriate authorization, except as permitted or required by law.
To support coordinated care, CFA staff may share information between CFA programs as permitted by law and CFA policy.
When more than one adult name is in a record, authorization from all applicable adults may be required before information is shared.
CFA’s role is to support the client’s mental and physical health and well-being. CFA does not participate in custody disputes or provide written recommendations relating to custody.
CFA continually evaluates its programs to improve services for children and families. De-identified information may be used for internal quality improvement, reporting, statistical purposes, and funding requirements. Any use of identifiable Protected Health Information (PHI) for external research will occur only with appropriate written authorization or approval by an Institutional Review Board (IRB) or Privacy Board, as required by law.

Client Rights
Clients have the right to:

Receive equal treatment without regard to race, color, spiritual beliefs, sex, gender identity, sexual orientation, and/or national origin.
Receive services that take into consideration the client’s culture and spoken language.
Participate actively in treatment planning, and ongoing decisions regarding services.
Review the client’s record, subject to applicable confidentiality laws and Agency policy.
Record reviews are conducted in the presence of the treating provider and/or supervisor. CFA will determine whether review or release of information may be harmful to a minor client, as permitted by law.
Subpoena CFA treating clinician or provider for written or verbal testimony. Fees may apply.
Request a change in staff assignment.
Refuse services at any time. The clients should discuss with their assigned clinician.
Seek another opinion from an individual or organization outside of CFA regarding diagnosis, medications, or treatment planning.
Decline any audio/audiovisual taping.
Receive information regarding risks, benefits, and alternatives associated with the proposed treatment or service plan.
Request information regarding the professional education and experience of the treating clinician.
Request a Good Faith Estimate.
Express concerns regarding services and request changes when appropriate.
Express concerns about the CFA policies and procedures.
The agency’s Grievance Procedure is available for review and reference on our website at Grievance Procedure

Client Responsibilities
Clients and parents/legal guardians are responsible for:

Maintaining a Safe and Respectful Treatment Environment

Treating CFA staff, family members, and other clients with respect.
Maintaining a safe and appropriate treatment environment.
Refraining from rude or obscene language, appearing under the influence of alcohol or other substances, and making verbal or physical threats while receiving services.
Understanding that threats and actions involving harm to oneself or others are not protected by confidentiality and may be reported to the appropriate authorities.
Ensuring that weapons are not brought onto CFA premises. When services are provided in the home, weapons must be disclosed, secured, and safely stored.
Understanding that behaviors that compromise the safety of clients, families, or CFA staff may result in changes to services, including discharge from CFA services.
Not recording, photographing, or otherwise capturing, or sharing or distributing, video, audio, or photographs of CFA services, staff, clients, or family members.

Participating in Treatment

Participating actively in treatment and attending scheduled appointments as recommended by the treatment team.
Following program expectations and treatment recommendations discussed during intake and throughout the course of services.
Providing accurate and complete information regarding medical history, medications, symptoms, and other information necessary for treatment.
Notifying CFA promptly of changes to contact information, insurance coverage, or legal custody that may affect treatment, communication, or service coordination.
Understanding that failure to participate in services, maintain attendance, or meet program expectations may result in discharge from CFA services.

Managing Financial Responsibilities

Providing and maintaining accurate and current financial, insurance, and contact information necessary to determine eligibility, billing, and payment for services.
Reviewing and signing CFA’s Financial Responsibility Agreement.

Telehealth Agreement
Telehealth allows CFA providers to diagnose/evaluate, consult, treat, educate, and manage care using interactive audio, video or data communication.

I agree not to record and/or distribute my telehealth therapy sessions.

Client Rights & Responsibilities Acknowledgement

I agree that I have received, read, and understand this Client Rights and Responsibilities document. I have had the opportunity to ask questions, and my questions have been addressed. I understand my rights and responsibilities as a client or parent/legal guardian of a client at CFA.

Date*

Client/Person to Receive Services Signature (if 13 years of age or older)

First Last

Signature

Date*

Parent/Legal Guardian Signature (if applicable)*

First Last

Signature*

FINANCIAL RESPONSIBILITY AGREEMENT

By signing this agreement, I acknowledge that I am the financially responsible party for the Client at Child & Family Agency of Southeastern Connecticut, Inc (CFA). This agreement applies to clients who: have HUSKY, commercial or military insurance, do not have insurance (self-pay), or choose not to use insurance for CFA services (private pay).

Understanding Insurance Costs
At CFA, we understand that healthcare insurance can be hard to understand and at times confusing. The information below confirms terms and ensures we have a common understanding of insurance terms:

Co-payment: a fixed dollar amount you pay directly to the service providers for a health care visit.
Deductible: a set dollar amount you pay yourself for care before insurance starts paying.
Co-insurance: a split percentage of the bill (such as 20% for you and 80% for the plan) that you pay after you meet your deductible.
Statement: CFA will send a monthly statement detailing any balances owed.

General Responsibilities
I agree to:

Provide current insurance information that confirms the Client’s eligibility to receive services. Should changes in insurance occur, new insurance information must be shared with CFA by the time of the Client’s next appointment.
Complete any additional paperwork or forms required by my insurance company to receive prior authorization for Client services.
Inform the Client’s provider if they are receiving similar services from another provider that could be duplicate services provided by CFA. This is important as it could create a situation where the insurance will not pay for one of the services.
Contact the CFA billing department if I have questions about insurance coverage, billing, payment arrangements, or financial assistance.

Payment Responsibilities
If applicable, I agree to:

Pay any insurance co-payment (co-pay) prior to or at the time of the visit.
Pay any deductible or co-insurance that remains after my insurance has processed the claim.
Pay the full cost of services if I do not have insurance or choose not to use my insurance per the fee schedule that follows.

Outstanding Balances
I understand that:

If the Client transitions from one CFA service to another, any outstanding balance must be paid in full prior to starting the new service.
If Client withdraws from a program with an outstanding balance, I remain accountable for paying the balance.
Failure to meet financial responsibilities may affect Client’s ability to schedule future appointments and could result in discontinuation of services.

Fee Schedule
For those clients with commercial or military insurance, CFA has either negotiated or accepted the rates set by your insurance company and will be disclosed on your explanation of benefits (EOB) or your monthly CFA billing statement.

The fee schedule below includes our base fee applicable for private pay or self-pay Clients. Based on specific services rendered during sessions, these could vary based on time spent.

* Note: CFA will make a Good Faith Effort to obtain and confirm insurance eligibility to bill insurance for these programs

Financial Assistance
If I am unable to pay my balance, I understand that I may contact CFA’s billing department by calling (860) 437-4550 Option 5 to discuss available payment options or determine whether I qualify for a reduced fee. To determine whether I qualify for financial assistance, CFA may ask me to:

Provide updated financial information
Share documentation of hardship
Agree to a specific payment arrangement

Release of Information: I authorize CFA to disclose and release to my insurance carrier(s), including Medicare, Medicaid, Medigap/Supplemental benefits providers, and private insurers, as applicable, any medical and treatment information needed for payment purposes for services rendered. I authorize use of this form for the release of information needed to process claims to all my insurance carrier(s) and its authorized agents. I authorize my provider/practice to act as my agent in helping obtain payment from my insurance companies.

Assignment of Benefits: I assign all payments, rights and claims for reimbursement of claims, costs and expenses allowable under my insurance plan(s) directly to my provider or practice for services rendered. I understand I will receive a statement for any balance due by me and I agree to make full payment upon receipt of the statement after insurance has met its obligation.

Medicare Authorization: If a Medicare beneficiary, I understand my signature requests payment to be made and authorize the release of medical information necessary to pay claims. If ‘other health insurance’ is indicated in item 9 of the HCFA-1500 Form, or elsewhere on approved claim forms, or electronically submitted claims, my signature authorizes the release of information to insurance companies or its authorized agents. In Medicare-assigned cases, the physician or supplier agrees to accept the charge of determination of the Medicare carrier as the full charge, and I agree I am responsible for deductible, coinsurance and non-covered services. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier.

Financially Responsible Party Signature Client (if over 18 years old) or Parent/Legal Guardian

Date*

Printed Name (First & Last):*

First Last

Signature*

SBHC Client Registration Form

SCHOOL BASED HEALTH CENTER (SBHC) CLIENT REGISTRATION

CLIENT INFORMATION

MEDICAL HISTORY

EMERGENCY CONTACT

INSURANCE INFORMATION

CONSENT FOR TREATMENT AND SERVICE AGREEMENT

SCHOOL BASED HEALTH CENTER OPT IN

SERVICE CONDITIONS AND EXPECTATIONS

Authorization for Electronic Communications

CONSENT FOR TREATMENT AND SERVICE AGREEMENT

ACKNOWLEDGEMENT AND SIGNATURES

Client/Person to Receive Services Signature (if 13 years of age or older)

Parent/Legal Guardian Signature (if applicable)

NOTICE OF PRIVACY PRACTICE

Your Information. Your Rights. Our Responsibilities.

NOTICE OF PRIVACY PRACTICES FOR SUBSTANCE USE DISORDER TREATMENT INFORMATION

Notice of Privacy Practices

CLIENT RIGHTS AND RESPONSIBILITIES

Client Rights & Responsibilities Acknowledgement

FINANCIAL RESPONSIBILITY AGREEMENT