All information on this registration must be dated and signed before your child can receive services from the School Based Health Centers (SBHC) at Child and Family Agency of Southeastern Connecticut, Inc. (CFA). If a student is 18 or older, they may sign their own permission form. Race & ethnicity information is required by the State and will be used for statistical purposes only.

STUDENT INFORMATION

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

First Last

Date of Birth*

Student Grade*

School that Person Receiving Services Attends (check box next to school):*

Address*

Street Address Address Line 2 City State ZIP Code

Assigned Sex*

Male

Female

Other

Ethnicity*

Hispanic

Non-Hispanic

Gender Identity

Male

Female

Transgender Male

Transgender Female

Non-binary

Other/Prefer not to Answer

Language Spoken at home:*

Race*

Unknown

American Indian

Pacific Islander

Alaskan Native

Black

Asian

White

Other

AGREEMENT TO RECEIVE SERVICES*

I am the legal guardian of a minor, who is receiving services. I have the authority to make decisions about treatment.

I am receiving services and I am over 18. I hereby agree to engage and participate in treatment.

SELF/PARENT/LEGAL GUARDIAN INFORMATION

Name*

First Last

Relationship to Student*

Parent

Legal guardian

Define*

Address (If different from above)

Street Address Address Line 2 City State ZIP Code

Secondary Emergency Contact

First Last

Emergency Contact Phone

ACKNOWLEDGEMENT AND CONSENT

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

I give permission for my child/self (>18 years old) to obtain routine health services at the School-Based Health Center.

RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION
I authorize the release of any medical or behavioral health information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency of Southeastern Connecticut, Inc. (CFA) for services provided.

CONSENT AND ACKNOWLEDGEMENT OF 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
I give permission to allow CFA to exchange as needed information with the client’s primary care provider, school nurse, and key school personnel in order to effectively care for my child. I understand that SBHC medical and mental health providers may communicate with each other about the client’s care.

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 SBHC of any changes.

Age-appropriate, annual risk assessment screenings are completed with students enrolled in the SBHC as part of best-practices in pediatric care. We offer an "opt-out" of this initiative for universal screenings, if indicated by the student/parent/legal guardian in the annual enrollment.

Opt out

Agency Grievance Procedures

A copy of the Grievance Procedure is available upon request and online.*

Click here to review the Grievance Procedures

I acknowledge CFA’s Grievance Procedures and where to find them.

Signature of Parent/Legal Guardian/Personal Representative (or Student if over 18 years old)*

Print Name

First Last

Date*

By signing above, 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. I understand that my child will continue to be enrolled in a CFA SBHC as long as child is enrolled in school that has a CFA SBHC, although yearly updates will be requested. I recognize that health records, if received by the school district, may not be protected by the HIPAA Privacy Rule, but will become education records protected by the Family Education Rights and Privacy Act.

Authorization for Health Information Exchange (HIE)

The HIE system is a secure computer system that brings your protected health information 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 across your care teams.

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 when sending data. Only those involved in your care can look at your information.

Student's Name*

First Last

Student's Date of Birth*

The State of Connecticut participates in the Health Information Exchange, meaning that medical health information (e.g. immunizations, medications, physical examinations, 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).

Patients must specifically authorize disclosures of sensitive PHI.*

I opt-in for 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.

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 by notifying Child and Family Agency of Southeastern CT, Inc. of the named recipient in writing.

Electronic signature of person authorizing health information exchange*

Relationship to Student (If <18 years of age):

Today's Date*

SBHC Registration Form-English

STUDENT INFORMATION

STUDENT’S PRIMARY CARE PROVIDER

MEDICAL HISTORY

SELF/PARENT/LEGAL GUARDIAN INFORMATION

COMMUNICATION AGREEMENT

INSURANCE INFORMATION

ACKNOWLEDGEMENT AND CONSENT

Agency Grievance Procedures

Authorization for Health Information Exchange (HIE)