Mobile & School-Based Care Form

Mobile and School-Based Care Form

School Year(Required)

School / Organization(Required)

If other, please list school

Patient Paperwork and Consent to Treat | Mobile and School-Based Care Form

I am providing consent for my child to participate in the following services provided by Jordan Valley Community Health Center School-Based/Mobile Unit Program (please select all that apply)(Required)

Medical: Sick Visits, Well Visits including Sports Physical, Telehealth

Dental: Routine check-up and/or restorative work

Vision: Eye exam

Behavioral Services

All services listed above

In addition to written consent, flouride treatment will also be confirmed via verbal consent at the time of service.

Today's Date

Grade(Required)

Patient Legal First Name(Required)

Patient Legal Last Name(Required)

Patient Preferred Name(Required)

Email(Required)

Social Security Number(Required)

Date of Birth(Required)

Sex Assigned at Birth(Required)

Male

Female

Preferred Language

Address(Required)

Street Address City State / Province / Region

ZIP / Postal Code

Race (check all that apply)(Required)

Ethnicity (check all that apply)(Required)

Hispanic or Latino

Not Hispanic or Latino

Other

Prefer not to answer

If Multi-racial or Other - Include information here

Other - Include information here

Number of Adults/Children in Your Household(Required)

Annual household income(Required)

INSURANCE

Patient is covered by Medicaid(Required)

Yes

If yes, Medicaid #

Patient is covered by Other Insurance(Required)

Yes

Name of Insurance

Group

Policy #:(Required)

Name of Policy Holder(Required)

Date of Birth(Required)

Social Security Number(Required)

Relationship to Policy Holder

PARENT/LEGAL GUARDIAN CONTACT

Parent/Legal Guardian Name(Required)

Date of Birth(Required)

Address(Required)

Street Address City State / Province / Region

ZIP / Postal Code

Relationship to Patient(Required)

Home Phone #

Work Phone #

Cell Phone #

Social Security Number(Required)

VISION

Does your child have vision problems?(Required)

Yes

If yes, what kind of problems is your child experiencing?

Nearsighted

Farsighted

Astigmatism

Other

If other, please explain

Has your child ever worn glasses or contacts?(Required)

Glasses

Contacts

Neither Glasses nor Contacts

MEDICAL

Does your child have any current or past medical conditions? (Examples: Asthma, Diabetes, Heart Disease, High Blood Pressure, Neurological Conditions, Allergies, etc.)(Required)

Yes

If yes, please list

Has the patient had surgery?(Required)

Yes

If yes, please list the type of surgery or surgeries and date(s).

Please list any medicine and supplements your child is taking.

Does the patient have any allergies?(Required)

Yes

If yes, please list

DENTAL

Has your child ever seen a dentist before?(Required)

Yes

If yes, date of last treatment

Name of your child’s dentist:

Has your child had any unpleasant experiences in a dental office?(Required)

Yes

If yes, please describe what happened and how we can make your child more comfortable

Does your child have any medical conditions that may affect or complicate treatment? This may include HEART, BREATHING, BLEEDING, SEIZURE, BEHAVIORAL, ALLERGIES, COMMUNICABLE DISEASE, GENETIC CONDITIONS, and/or IMMUNE DISORDERS.(Required)

Yes

If yes, please list:

Acknowledgements and Authorizations

Consent to Share Protected Health Information

Sharing Your Information Jordan Valley Community Health Center (JVCHC) uses a tool to electronically submit prescriptions on your behalf to the pharmacy of your choice. Limited information about you and the medication will be securely transmitted to support the prescription order. JVCHC will sometimes utilize your contact information including phone, text, email, and mail to send you appointment reminders, information about the clinic, health education, and information which may contain protected health information, or to ask for feedback. Please help us keep your contact information up to date including your phone number, home address, and email. Limited Verbal Release of Protected Health Information (PHI) Jordan Valley Community Health Center (JVCHC) gives you the option to name other persons who can contact JVCHC to talk to JVCHC about your (or your dependent’s) care, treatment, payment, or appointment schedules. These people cannot make decisions about your (or your dependent’s) care. JVCHC will ask these people to identify themselves before sharing PHI. PHI will not be shared with persons who are not authorized by you. I authorize limited release of my PHI as told above to the following person(s): “ and the ‘full legal name, relationship, DOB, and phone.

Full Legal Name(Required)

Relationship(Required)

Date of Birth(Required)

Phone

Authorization for Consent to Treat a Minor Form

Unless a child (i.e. minor) has a life-threatening injury or illness, doctors are required by law to have permission from the parent or legal guardian to treat anyone under the age of 18. This form is necessary when a child under the age of 18 needs care and is not with their parent or guardian. Jordan Valley will not provide care for children in the care of a relative or baby-sitter without a written consent from their parent or legal guardian.

Patient Name:(Required)

Date of Birth(Required)

Parent/Guardian Name(Required)

Date of Birth(Required)

This consent is good for one year from the date of signature.

Patient Name(Required)

Date of Birth(Required)

Legal Guardian/Guarantor Full Legal Name (if applicable)(Required)

Acknowledgement of JVCHC Billing and Payment Practices

Jordan Valley Community Health Center (JVCHC) is committed to providing patients the highest quality of care and pursuing excellence in our services and interactions. We share this information with you to help you understand and prepare for your care and responsibilities as a patient of JVCHC.

OCHIN Epic Information Sharing

Click here to read the Acknowledgement of OCHIN Epic Information Sharing. Read less ▾

Acknowledgement of OCHIN Epic Information Sharing | Jordan Valley Community Health Center (JVCHC) is part of an organized health care arrangement including participants in OCHIN. A current list of OCHIN participants is available at www.ochin.org. As a business associate of JVCHC, OCHIN supplies information technology and related services to JVCHC and other OCHIN participants. OCHIN also engages in quality assessment and improvement activities on behalf of its participants. For example, OCHIN coordinates clinical review activities on behalf of participating organizations to establish best practice standards and assess clinical benefits that may be derived from the use of electronic health record systems. OCHIN also helps participants work collaboratively to improve the management of internal and external patient referrals. Your personal health information may be shared by JVCHC with other OCHIN participants or a health information exchange only when necessary for medical treatment or for the health care operations purposes of the organized health care arrangement. Health care operation can include, among other things, geocoding your residence location to improve the clinical benefits you receive. Personal health information may include past, present, and future medical information as well as information outlined in the Privacy Rules. The information, to the extent disclosed, will be disclosed consistent with the Privacy Rules or any other applicable law as amended from time to time. You have the right to change your mind and withdraw this consent; however, the information may have already been provided as allowed by you. This consent will remain in effect until it is revoked by you in writing. If requested, you will be provided with a list of entities to which your information has been disclosed. If you wish to decline OCHIN Epic Information Sharing, please email Jordan Valley [email protected] or call (417) 851-1556.

Additional Acknowledgements and Authorizations

Notice of Privacy Practices for Tiger Institute Health Information Exchange

Click here to read the Acknowledgement of Notice of Privacy Practices for Tiger Institute Health Information Exchange. Read less ▾

Notice of Privacy Practices for Tiger Institute Health Information Exchange | Jordan Valley Community Health Center (JVCHC) participates in a Health Information Exchange provided through the Tiger Institute Health Information Alliance. Exchange facilitates the transmission of your medical record between providers who are treating you, replacing other types of communication methods such as the telephone. Fax machine, and the US Postal Service. With your written permission, the Exchange permanently stores your data in a secured repository for providers who may treat you in the future, if they have established a treatment relationship with you. The Exchange may also provide critical information about you for other lawful purposes, such as to educate providers who manage the care of others like you, but in doing so will not share your names, address or other information that could Identify you. In those cases where your specific consent or authorization is required by law to disclose your medical records to others, JVCHC will not disclose that information through the Exchange without first obtaining your written consent. If you wish to decline Tiger Institute Health Information Exchange, please e-mail Jordan Valley compliance@ jordanvalley.org or call 417-851-1556.

I acknowledge the previous information, and I permit limited release of my/or my dependents PHI as described previously.

If the patient is not 18 years or older, parent or legal guardian signature is required.

Patient (if 18 years or older) OR Parent/Legal Guardian/Guarantor (Type Name)(Required)

Date of Birth(Required)

If you wish to change PHI or revoke this consent, want to obtain a copy of the Patient Rights and Responsibilities and/or Notice of Privacy Practices, and/or withdraw from OCHIN and/or Tiger Institute Care Everywhere information sharing, please submit your request(s) in writing to [email protected] . For questions about these consents, call Compliance at (417) 851-1556.

Click here to access Our new MyChart patient portal!

Senior Care

Senior Care

Mobile & School-Based Care Form

Mobile and School-Based Care Form

Patient Paperwork and Consent to Treat | Mobile and School-Based Care Form

INSURANCE

PARENT/LEGAL GUARDIAN CONTACT

VISION

MEDICAL

DENTAL

Acknowledgements and Authorizations

Consent to Share Protected Health Information

Authorization for Consent to Treat a Minor Form

Acknowledgement of JVCHC Billing and Payment Practices

OCHIN Epic Information Sharing

Additional Acknowledgements and Authorizations

Notice of Privacy Practices for Tiger Institute Health Information Exchange