School Based Mobile Unit Intake Form

Mobile Event Information

Select One

School Teacher Grade

Based on what you selected above, please fill in the corresponding text box below.

Community

School Name

Teachers Name

Grade

PATIENT INFORMATION

Last Name:

First Name:

MI:

Social Security Number:

Date of Birth:

U.S. Military Service (Select One:)

None Currently Serving Discharged

Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Email:

Marital Status (Select One):

Single Married Widowed Separated Divorced

Primary Language Spoken:

Limited English

Patient’s Relationship to Responsible Party (Select One):

Self Spouse Natural Child Parent Foster Child Foster Parent

Gender (Select One):

Male Female Choose Not To Disclose

Race (Select One):

Asian Native Hawaiian Other Pacific Islander Black/African American American Indian/Alaska Native White More Than One Race Choose Not To Disclose

Ethnicity (Select One):

Hispanic/Latino Non-Hispanic/Latino Choose Not To Disclose

Are you a migrant/seasonal worker or a family member of a migrant/seasonal worker?

Yes No

What is your annual income?

$0-$14,580 $14,581-$18,225 $18,226-$21,870 $21,871-$25,515 $25,516-$29,160 $29,161 & UP

How many people (including you) does your income support?

Emergency Contact:

Phone:

Relationship to Patient:

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

Last Name:

First Name:

MI:

Mailing Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Date of Birth

Social Security Number:

INSURANCE COMPANY – INCLUDING MEDICAID

Primary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Secondary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Assignment and Release

I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.

SIGNATURE:

DATE:

HEALTH HISTORY

Reason for Today’s Visit:

If Pregnant, Due date:

Last Pap Smear:

Last Mammogram:

Number of Pregnancies:

Number of Births:

Birth Control Method:

None Pill Condoms IUD Shots Tubal Vasectomy Other

If Other, please specify:

Allergies:

Medications:

Pharmacy Name:

Pharmacy Location:

Hospitalization/Surgeries:

Dental Pain:

Yes No

If yes, explain:

FAMILY HISTORY

Check all that apply to you and your family:

Alcohol Abuse

Asthma

Cancer

Depression

Diabetes

Glaucoma

Heart Disease

High Blood Pressure

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform the doctors at the next appointment without fail.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient, Parent, or Guardian Signature:

Date:

Dental Provider Signature:

Date:

Medical Provider Signature:

Date:

Notice of Privacy Practices/Patient Rights and Responsibilities

Initials:

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this organization’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I also understand that the Patient Rights and Responsibilities are available for my review and that I have responsibilities regarding my care.

I understand that:

I have the right to review this organization’s Notice of Privacy Practices prior to signing this acknowledgement;
I have the right to review the Patient Rights and Responsibilities prior to signing this acknowledgement;
This organization reserves the right to change these documents and that these documents are available to me upon request at my next visit, and on the organizations web site: www.pancarefl.org.

Consent for Treatment

Initials:

I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated physicians, dentists, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.

Release of Medical/Dental Information

Initials:

It is the provider's responsibility to ensure that the provider-patient relationship is confidential. Under the requirements of the Health Insurance Portability and Accountability Act (HIPAA), we are not allowed to release any patient information without the patient's consent. If you wish to have your medical/dental or billing information released to a family member, friend, or legal representative, you must sign this form. Signing this form will give consent to release this information to only the persons indicated below. This consent form will not allow PanCare Health to release any other information to these persons. You have the right to revoke this consent in writing.

I authorize/allow PanCare Health to release my medical/dental and/or billing information to the following individual(s):

Name:

Relationship to Patient:

Name:

Relationship to Patient:

Name:

Relationship to Patient:

Acknowledgement

I have initialed the Notice of Privacy Practices/Patient Rights and Responsibilities and Consent for Treatment. By doing so I acknowledge that I have read all of the aforementioned statements and will abide by the same and if I do not this may disqualify me from receiving care from PanCare Health/Dental Clinic.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Legal Representative:

Date:

Name of Patient/Legal Representative:

Your information will be encrypted.