School-Based Services Appointment Request and Registration

Registration Information
How do you want to complete your registration information?*

Online with this formI prefer to give the rest of my registration information over the phone - please call me at the above phone number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this also the address where you live?*

YesNo
Physical / Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Health Insurance Information
Do you/does the student have health insurance?*

YesNo
Health Insurance Name*
Group ID #*
Member ID #*
When did the health insurance start?*

MonthDayYear
Date
Are you the insurance subscriber?*

YesNoUnsure
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
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:

Mental health diagnoses, prognosis, and treatmentSubstance use diagnoses, prognosis, and treatmentPregnancy informationHIV / AIDS VirusSexually Transmitted Diseases
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

Clear
Date

MonthDayYear
Date
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

Registration Information

Health Insurance Information

Sharing Your Visit with Your Primary Care Doctor