South Wasco County School District Appointment Request Form

South Wasco County School District Appointment Request Form

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One Community Health's Mobile Medical Clinic (La Clínica) will be offering medical services to all students at South Wasco County School District starting January 2025!

La Clínica will be onsite (308 Deschutes Ave, Maupin, OR 97037) twice per month. To view dates and times, follow us on Facebook or Instagram, or visit our website.
Who is completing this form?*

Patient/StudentParent/Guardian of the Patient/Student
Patient/Student*

First NameLast Name
Patient/Student Date of Birth*

MonthDayYear
Date
Patient/Student Preferred Pronouns
Patient/Student Gender Identity
Parent/Guardian*

First NameLast Name
Parent/Guardian Phone Number*
Parent/Guardian Email
example@example.com
What is your preferred language?*

EnglishSpanishOther
Is there anything else you would like us to know/ Do you have any questions?

Registration Information
How do you want to complete your registration information? (address, health insurance, etc.)*

Online with this form (Recommended)I 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
Does the student have health insurance?*

YesNo
What type of insurance do you have?*

Medicaid (Oregon Health Plan or Washington Apple Health)Other
Front of insurance card
Back of insurance card
Medicaid Member ID
Name of Health Insurance*
Group ID # (if applicable)
Member ID #*
Subscriber Information*

Subscriber NameSubscriber's relationship to patient/student
Subscriber Date of Birth*

MonthDayYear
Date
Claims Address (usually on the back of your card)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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 aam receiving services via One Community Health's School Based Health Services.
- 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
For personal representatives - relationship to patient

Authorization for Treatment of Unaccompanied Minor Children

General Consent to Evaluate and Treat Unaccompanied Minor
I,name of parent/guardian authorize One Community Health to treat my minor child, First Name Last Name when unaccompanied, for routine and emergency medical treatment.

EXCLUSIONS: Minor medical procedures (i.e. wart, mole, or toenail removal, etc.).
If your child is scheduled for a well-child check and/or sports physical during the visit – in addition to this form, you will also need to fill out the Health History Questionnaire and the OSAA Pre-Participation Sports Physical Exam Questionnaire.

I UNDERSTAND that both the Unaccompanied Minor Authorization, Health History
Questionnaire and the OSAA Pre-Participation Sports Physical Exam Questionnaire
are required in order to complete a Well Child/Adolescent Visit and/or Sports Physical. If not completed, the patient will be rescheduled.
Consent to Vaccinate Unaccompanied Minor

I authorize One Community Health to provide vaccines to my minor child, when unaccompanied, according to the routine childhood immunization schedule.I DO NOT authorize One Community Health to provide vaccines to my minor child, when unaccompanied, according to the routine childhood immunization schedule.
If your child will be receiving immunizations during the visit – in addition to this form, you will also need to fill out the Child and Teen Immunization Screening Form.

• One screening form is required for each immunization visit, every time immunizations are given.

• I UNDERSTAND that both the Unaccompanied Minor Authorization, and the Child and Teen Immunization Screening Form are required to administer immunizations to an unaccompanied minor. If not completed, the patient will not receive vaccinations during their visit.
This authorization will automatically expire in one year from the date signed below unless you wish it to expire sooner. If so, enter date: MM/DD/YYYY
- I UNDERSTAND I must have an existing, valid phone number on file in my minor child’s chart for verification and contact purposes.
- I UNDERSTAND that I can select either or both of the options listed above.
- I UNDERSTAND that I may revoke this request in writing. If revoked, it would not affect any actions already taken by One Community Health based upon this authorization.
Name of Parent/Legal Guardian

First NameLast Name
Signature

Clear
Todays Date

MonthDayYear
Date

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

South Wasco County School District Appointment Request Form

Registration Information

Health Insurance Information

Sharing Your Visit with Your Primary Care Doctor

Authorization for Treatment of Unaccompanied Minor Children