Coplin Wellness Center Registration Form for Telehealth

COPLIN HEALTH SYSTEMS
Patient Demographics
Patient Full Name*
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemaleUnknown
Student Social Security Number
Student Preferred Name
Student Address*

Street Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Student Home Phone*
Cell Phone
Student Work Phone
Student School
Student Grade
Communication Preference (For office communication and appointment reminders)

VoiceTextEmail
Student Email

Does not have emailWill not discloseOtherEmail Address (Patients email only; not for the guardian):
Student Preferred Provider/Doctor
Student Primary Care Provider/Doctor
Language*

EnglishSpanishOther
Translator Needed

YesNo
Responsible Party (Responsible for Bill)
Name of Responsible Party
Birthdate of Responsible Party

MonthDayYear
Date
Address of Responsible Party

Mailing Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Home Phone Number of Responsible Party
Cell Number of Responsible Party
Work Number of Responsible Party
Responsbile Party's Relationship to Patient
***Parent/Guardian Information (court issued guardian/custody documentation is required)
Father's Name
Father's Email
example@example.com
Father's Home Phone Number
Father's Work Phone Number
Father's Cell Number
Mother's Name
Mother's Maiden Name
Mother's email
example@example.com
Mother's Home Phone Number
Mother's Work Phone Number
Mother's Cell Phone Number
Guardian's Name
Guardian's email
example@example.com
Guardian's Home Phone Number
Guardian's Work Phone Number
Guardian's Cell Number
Emergency/Alternate Contact Information
I understand that by providing an alternate contact if I cannot be reached, medical information regarding the above-named child will be shared between the medical provider and the alternative contact (including all relevant information with exception to psychiatric/mental health, alcohol/drugs, and HIV/AIDS information).
Emergency/Alternate Contact Name
Emergency/Alternate Contact Relationship to patient
Emergency/Alternate Contact's Address
May we leave a message with the Emergency/Alternate Contact

YesNo
Emergency/Alternate Contact's Home Phone Number
Emergency/Alternate Contact's Work Phone Number
Emergency/Alternate Contact's Cell Number)
Consent to share Protected Health Information
I Authorize Coplin Health Systems to share my personal health information (PHI) with the named persons below. (Please indicate which information Coplin Health Systems is authorized to share with each named person)
Name of individual permitted to PHI
Date of Birth of individual permitted to PHI

MonthDayYear
Date
Relationship to Patient of individual permitted to PHI
Phone number of individual permitted to PHI
Information permitted to share with the individual permitted to PHI

MedicalDentalBillingSchedulingBehavioral HealthSUDSHIV/AIDSALL
Name of additional individual permitted to PHI
Date of Birth of additional individual permitted to PHI

MonthDayYear
Date
Relationship to Patient of additional individual permitted to PHI
Phone number of additional individual permitted to PHI
Information permitted to share with the additional individual permitted to PHI

MedicalDentalBillingSchedulingBehavioral HealthSUDSHIV/AIDSALL
Insurance Information
Insurance

Student does not have health insuranceRequest for sliding fee applicationRequest for assistance from Coplin Health Systems to obtain insurance
Primary Health Insurance: Name of Insured Parent / Guardian
Date of Birth of Card Holder

MonthDayYear
Date
SSN of Card Holder
Address of Card Holder (if different from child)
Place of Employment of Card Holder
Name of Insurance Company
Insurance ID Number
Insurance Group Number
Secondary Health Insurance
Secondary Health Insurance: Name of Insured Parent / Guardian
Date of Birth of Card Holder

MonthDayYear
Date
SSN of Card holder
Address of Card Holder (if different from child)
Place of Employment of Card Holder
Name of Secondary Insurance Company
Insurance ID Number
Insurance Group Number
Dental Insurance
Dental Insurance: Name of Insured Parent/Guardian
Date of Birth of Card Holder

MonthDayYear
Date
SSN of Card Holder
Address of card holder (if different from child)
Place of Employment of card holder
Name of Dental Insurance Company
Dental Insurance ID Number
Dental Insurance Group Number
Secondary Dental Insurance:
Dental Insurance: Name of Insured Parent/Guardian
Date of Birth of Card Holder

MonthDayYear
Date
SSN of Card Holder
Address of Card Holder (if different from child)
Place of Employment of Card Holder
Name of Dental Insurance Company
Dental Insurance ID Number
Dental Insurance Group Number
I agree to allow Coplin Health Systems to access my prescription history*

YesNo
I agree to leave my credit/debit card on file

YesNo
I agree to have nursing and/or medical students present during my care

YesNo
Current Medications & Health Information

	Medication	Dose (mg)	Directions
Medication 1
Medication 2
Medication 3
Medication 4

Allergies

	Allergen	Reaction
Allergy 1
Allergy 2
Allergy 3
Allergy 4
Allergy 5

Patient's Doctor's name
Date of last well child exam

MonthDayYear
Date
If we need to call in a prescription, which pharmacy would you like us to call?
Coplin Health Systems is a Federally Qualified Health Center, and we qualify for special pricing and discounted costs to our patients. To ensure that we continue to receive this designation and funding, we must report specific information about the population that we serve. We ask that you assist us by completing the following information.
How many people are currently living in your household?

123456789
What is your estimated household monthly net income?

$100-500$501-1000$1001-1500$1501-2000$2000-2500$2501-3000$3001-3500$3501-4000$4001-4500$4501-5000$5001-5500$5501-6000
Household Status

Own my homeRentLive with someoneIn ShelterTransitionalHomeless
Gender

FemaleMaleTransgender MaleTransgender FemaleOtherChoose not to disclose
Sexual Orientation

StraightLesbian/GayBisexualOtherDon't KnowChoose not to disclose
Military Status

Not a veteranVeteranActive Service
Does the patient have a disability as identified by the Americans with Disabilities Act?

YesNo
Race*

WhiteBlackAmerican Indian/Alaskan NativeNative Hawaiian/Pacific IslanderAsianNative AmericanOther
Ethnicity*

Not Hispanic/LatinoHispanic/LationDecline to SpecifyOther
Telehealth Consent
1.      I understand that SBHC medical and behavioral health services may be completed via telehealth in place of face-to-face visit(s). I understand that these encounters will not be the same as a direct patient/health care provider visit because the provider will not be in the same room. Instead, two-way simultaneous audio-visual technology will be utilized.

2.      I understand that I/my dependent has the right to refuse to participate in any telehealth encounter at any time or to end it at any point during the encounter. I understand that if I/my dependent do(es) not wish to participate in a telehealth encounter, other healthcare arrangements will need to be made. I further understand that the provider may not be able to accommodate an in-person visit, and there may be a delay in care if an in-person visit is chosen.

3.      I understand that the provider can discontinue the telehealth visit if he or she believes that this technology does not meet the standard of care necessary to address the concerns. If that happens, I understand an appointment for an in-person visit with a provider will need made, or I should seek care at the closest emergency department if I believe that symptoms warrant that level of care.

4.      I understand how the technology will be used to conduct any telehealth visit with this practice. I also understand that, with this technology, there is a risk of interruption and technical difficulties.

5.      I understand that the identity of everybody who will be in the room with my healthcare provider will be disclosed during any telehealth encounter and that those people will be present only because the provider has determined that their presence is necessary to assist in medical treatment according to the applicable standard of medical care.

6.      I understand that I will be responsible for any co-pays and coinsurance that apply to the telehealth visit(s).

7.      I understand that the provider may use this technology to take a picture to be used for my care. The provider will inform me before this is done. These photographs will be treated and protected just as any other protected health information. Outside of this, video and photographs are not recorded nor stored from telehealth visits.

8.      I understand that the same laws that protect the confidentiality of personal information also apply to telehealth. In all but a few rare situations, my confidentiality is protected by state law and by the rules of licensing boards. The most common cases in which confidentiality is not protected include, but are not limited to: Child and vulnerable adult abuse expressed imminent harm to oneself or others, and as part of legal proceedings where information is required by court of law.

9.      I understand that Coplin Health Systems has an integrated Behavioral Health program, and patient records are shared between Behavioral Health and Medical, and are only viewed as allowable by law, with all records kept confidential and protected.

10.   I understand that care via telehealth is not the same as in-person services, and therefore the results, despite every effort of the provider, may not be the same. I understand that I may benefit from telehealth services, but results cannot be guaranteed or assured.

11.   I understand that telehealth services are considered outpatient services and are not intended to substitute for emergency or crisis services.

12.    This consent will remain valid for twelve (12) months from the date of signature.
Please initial if you consent to Medical Services through Telehealth for the patient*
Please initial if you consent to Behavioral Health Services through Telehealth for the patient
Consent and Signature
I, the legal parent/guardian, with my signature on this form, give consent for my child to receive services at Coplin Health Systems. I have read, understand, and agree to all the above as I have selected. The information is correct to the best of my knowledge. I understand that this consent form will be good for one year or until I provide Coplin Health Systems with written directions otherwise, whichever is shorter. By signing the consent form, I am giving Coplin Health Systems, the school nurse, and my child's regular doctor (if applicable) permission to communicate and share medical information regarding this applicant's medical condition on an as-needed basis with the understanding that this information will continue to be treated confidentially. No student will be denied access to health care services due to the inability to pay. As in any health center, there may be a charge depending on the service provided. I agree that when available, my insurance or Medicaid can be billed. The health center may release information regarding treatment to third-party payors for billing purposes. I understand that I am financially responsible for any balance. I understand and agree to the financial policy. Confidentiality between the student, parents, and the health center is assured. I understand how to obtain a copy of the Notice of Privacy Practices from a Patient Representative, viewed on the lobby wall, or on the website at www.coplinhealth.com. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur for my treatment, payment of bills, or in the performance of Coplin Health Systems' care operational and other purposes that are permitted and required by law. It also describes my rights to access and control my protected health care information. I understand and agree for my information will be shared with the WV and OH Health Information Networks, CommonWell, CareQuality and Surescripts; if I want to remove this access, I understand that I will need to provide a written statement to opt out. I agree that by providing contact information, Coplin Health Systems may contact me or those listed above. I understand that if guardianship changes, the legal guardian must sign a new consent. The documentation for guardianship and custody must be provided with the registration form and anytime there are updates.

Coplin Health Systems is a Federally Qualified Health Center (FQHC), and as such we qualify for special pricing and discounted costs for our patients.
Name of Patient or Responsible Party*
Signature of Patient or Responsible Party*

Clear
Date

MonthDayYear
Date
Should be Empty:

COPLIN HEALTH SYSTEMS

Patient Demographics

Responsible Party (Responsible for Bill)

Emergency/Alternate Contact Information

Consent to share Protected Health Information

Insurance Information

Dental Insurance

Current Medications & Health Information

Telehealth Consent

Consent and Signature