School-Based Services Appointment Request and Registration

Health Insurance Information

If you have health insurance and would like to use it, please bring it to your appointment
Do you/does the student have health insurance?
Health Insurance Name
Group ID #
Member ID #
When did the health insurance start?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you the insurance subscriber?
What is the insurance subscriber's name?
Subscriber's date of birth
What is the subscriber's relationship to you?

Sharing Your Visit with Your Primary Care Doctor

One Community Health (OCH) will only release Protected Health Information (PHI) as permitted by patient confidentiality laws. OCH reserves the right to use or disclose patient’s PHI without patient’s consent to the extent allowed by applicable law,including but not limited to uses or disclosures identified in OCH’s Notice of Privacy Practices.
Your primary care doctor

First NameLast Name
Phone Number
Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Protected information to share: Certain information cannot be released without specific authorization as required by state or federal law. By checking the specific boxes below,you authorize the disclosure of the following protected information with your doctor:
Authorization
- I understand that this authorization is valid as long as I am a patient of Hood River Valley High School Health Center, or I revoke my
  authorization.
- I understand that I may revoke this authorization in writing at any time but that revocation of this authorization will not apply to
  information already released.
- This form is not valid unless signed and dated.
Signature of patient or representative - use your finger on a phone or mouse on a computer to sign
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Patient or Representative

First NameLast Name
Relationship of Personal Representative

Please click the submit button to complete this form. If you entered your email address you will receive a confirmation email.
Should be Empty:

SBHC Appointment Request and Registration