Register Form EN – Human Services Council

Student Information

Last Name

First Name

Middle Name

Sex

MF

Date of Birth

Grade

Home Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

School select the school your student attends

Norwalk High SchoolNathan Hale Middle SchoolRoton Middle SchoolWest Rocks Middle School

Household who lives with the student

MotherFather

Number of Siblings

Total People in Household

Other (please explain)

Race & Ethnicity per federal OMB guidelines

Primary Care Provider

Child's Doctor / Clinic

Phone

Relationship & Eligibility

Your Relationship to Student

GuardianOther

Does your child receive free or reduced-price lunch?

YesNo

Contact

Parent or Guardian Name

Phone

Relationship to Student

Emergency Contact (if different than above)

Name

Phone

Relationship to Student

Insurance

Does your child have Insurance / Medicaid?

YesNo

Medicaid Number

Carrier Name

Group Number

Policy Number

Policy Holder Name

Policy Holder Date of Birth

Effective Date of Coverage

If you do not carry health insurance, or your insurance does not cover our services, there is no charge to you. Services are provided at no out-of-pocket cost.

Notice of Privacy Practices

How HSC uses your child's health information: for treatment, payment, and health care operations. Your information is not used or disclosed for another purpose without written authorization, except where permitted or required by law.

Read the Notice of Privacy Practices summary

Your rights regarding medical information include the right to: inspect and copy medical and billing records; request an amendment; request an accounting of disclosures; request restrictions; request confidential communication; receive a paper copy of the notice; and be notified of a breach of unsecured information.

HSC–SBHC may use or disclose health information without written authorization for treatment coordination, payment activities, health care operations, fraud or abuse detection, when required by law, or to avert a serious threat to health or safety.

If you believe your privacy rights have been violated, you may submit a written complaint to: HSC Program Director, Dr. Robert E. Appleby School Based Health Centers, Human Services Council, One Park Street, Norwalk, CT 06851.

I acknowledge that I have read and received a copy of the Notice of Privacy Practices.

Permission Form

Signing on behalf of
Student name

I give permission for the student identified in this application to obtain services at the Dr. Robert E. Appleby School Based Health Centers (SBHC) while they are in school. This permission remains in effect throughout the time my student is attending Norwalk Public Schools unless I withdraw it in writing.

My signature below indicates that I have read the information packet describing SBHC services and have received the Notice of Privacy Practices above. I give permission for the exchange of relevant health and safety information between the SBHC and appropriate school staff, within the confines of HIPAA and FERPA. If my student is referred to Norwalk Hospital, I give permission for Norwalk Hospital staff to release related treatment information to the SBHC. I authorize the SBHC to release treatment and billing information to my named insurance provider and authorize payment to be made directly to Human Services Council for services provided.

Signing As

Parent / GuardianStudent (18 or older)

Signature (type full legal name)

Date

Medical History select Yes if applicable, and explain

Date of Last Dental Visit

Dentist Name

Health Conditions has your child ever had any of the following?

Health Concerns

Please list any concerns you have regarding your child's health

Family History check any conditions that run in the family and note the relative

Enrollment Form

Form received

Our programs educate, safeguard and empower the Greater Norwalk community every day to help people reach their full potential.

Subscribe to our Newsletter

If you suspect child abuse or neglect in someone you know, please call now.

Connecticut Department of Children and Families

24 hours a day / 7 days a week