School Based Health Center Registration Packet (2021-2022)

Mora Valley Community Health Services, Inc.

School Based Health Center

2022-2023

Parents/Guardian(s):

On behalf of MVCHS’ School Based Health Center (SBHC), I am happy to welcome you to the 2022-2023 school year! The SBHC is looking forward to a productive partnership with you to ensure your child receives quality care and access to meet your child’s primary care needs. Healthy kids make better learners. That is why our goal is to help kids stay well and succeed in life.

It is important for you to complete and sign the enclosed consent form in order for your child to obtain medical care at the SBHC. If you do not complete and sign the parental Consent Form, your child can only be treated in an emergency situation or given first aid. Remember if you have not completed a Registration Form prior to completing the Consent Form please do so. Once a Registration Form is filled, you are not required to fill out another one unless to update your personal information.

Students may make their own appointments or parents/guardians may make the appointment for their children. Parents are always welcome to accompany their children.

Again, I encourage you to complete and sign the enclosed Consent Form and bring it to the SBHC. The SBHC is located on the South-West side of the Administration Building. If you have any questions please feel free to contact me at 575-387-3117 or at vmartinez@mvchs.org. If we can help, just ask!

Our very best for a bright and happy school year,

Vanessa Martinez, School Based Health Center Coordinator
Mora Valley Community Health Services, Inc.

Annual Patient Registration Form for SBHC Services
Patient Name (last, first, middle)*
Date of Birth*

MonthDayYear
Date
Social Security Number
Student ID Number
Grade*
Patient Address (street, city, state, and zip)*
Patient Phone - Home
Patient Phone - Cell
Parent(s)/Legal Guardian(s) Name(s)*
Patient Sex

MaleFemale
Patient Race*

BlackWhiteNative American/Alaska NativeHispanic
Parent(s)/Legal Guardian(s) Address (street, city, state, and zip)*
Home Phone*
If none , please enter N/A
Work Phone*
If none , please enter N/A
Cell Phone*
If none , please enter N/A
Emergency Contact Person Name and Relationship to Patient *
If none , please enter N/A
Emergency Phone - Home*
If none , please enter N/A
Emergency Phone - Cell*
If none , please enter N/A
Emergency Phone - Work*
If none , please enter N/A
Primary Care Provider*
If none , please enter N/A
Primary Care Provider Phone Number*
If none , please enter N/A
Primary Care Provider Address*
If none , please enter N/A
**Annual comprehensive well exams are recommended by the American Academy of Pediatrics to ensure health concerns are identified and treated long before they become chronic. If you have a primary care provider, but have not had a well exam in the last 12 months please schedule one with your primary care provider.**
Comprehensive Well Exam (physical, EPSDT, well child visit, annual check-up) in last 12 months?*

YesNoNot Sure
If you do not have a primary care provider, the SBHC is able to provide a well child exam for you (your child). Would you like your child to have a well exam in the SBHC this school year?*

YesNo
List any allergies:*
If none , please enter N/A
List any health/chronic health conditions:*
If none , please enter N/A
List hospitalizations or surgeries: (When and Where)*
If none , please enter N/A
List current medications/dosages:*
If none , please enter N/A
List any family health conditions which may be inherited (i.e. high blood pressure, heart disease, diabetes):*
If none , please enter N/A
Name of Health Insurance *
If none , please enter N/A
Medicaid Coverage *

YesNo
Insurance*

Blue Cross/Blue Shield CCPresbyterian CCWestern Sky CCOther
Policy Number*
If none , please enter N/A
Medicaid Number*
If none , please enter N/A
Name of Policy Holder*
If none , please enter N/A
Relationship to Patient*
Mora Valley Community Health Services, Inc.

SBHC Consent for Services
I give permission for my child to receive SBHC services while he/she is enrolled at the Mora Independent School District and for SBHC staff to access my child's class schedule (for appointment purposes only). I understand that SBHC services are confidential, except in a life-threatening situation or when emergency services are needed and in accordance with the law. I give permission to the SBHC to exchange pertinent information to appropriate persons, including school nurses and counselors, for the purpose of providing healthcare, diagnosis, treatment and counseling services, as well as for maintaining quality and safety. I understand that SBHC health records are confidential and will not be shared unless written consent is provided by the student and/or parent/guardian. I have received a copy of the HIPAA Notice of Privacy Practices. I understand that New Mexico law does not require parental consent for treatment or advice about sexually transmitted diseases, pregnancy or contraception to minors under 18 years of age and behavioral health counseling services to minors age 14 years or older. Unless I choose to withdraw my consent in writing, this authorization will continue for the entire period of time my child is enrolled in this school.
Students Name *

First NameLast Name
Signature of Parent or Guardian:*

Clear
Date*

MonthDayYear
Date
Signature of Student, if 18 years or older:

Clear
Date:

MonthDayYear
Date
Mora Valley Community Health Services, Inc.

About Our Notice of Privacy Practices
We are committed to protecting your personal health information in compliance with the law. The attached Notice of Privacy Practices states:

-Our obligations under the law with respect to your personal health information.
-How we may use and disclose the health information that we keep about you.
-Your rights relating to your personal health information.
-Our rights to change our Notice of Privacy Practices.
-How to file a complaint if you believe your privacy rights have been violated.
-The conditions that apply to uses and disclosures not described in this Notice.
-The person to contact for further information about our privacy practices.

We are required by law to give you a copy of this notice and to obtain our written acknowledgement that you have received a copy of this notice

Patient Acknowledgement of Receipt
Parent's Name*

First NameLast Name
Patient's Signature, If 18 years or older

Clear
Date

MonthDayYear
Date
Signature of Parent or Patient's Representative (if applicable)*

Clear
Date*

MonthDayYear
Date
Description of Legal Authority to Act on Behalf of Patient
Date

MonthDayYear
Date
Should be Empty:

Mora Valley Community Health Services, Inc.

Mora Valley Community Health Services, Inc.

Mora Valley Community Health Services, Inc.