TCP-819 5/13 Thank you for choosing Texas Children’s Pediatrics Date Completed Primary Care Provider Patient Registration Form (Please fill in all fields completely) Patient Information Child’s Full Legal Name (Last, First, Middle) Date of Birth Sex Preferred Name Other Children in family: Child’s Street Address (City, State, Zip Code) Telephone#where child lives Parent ’s Work # Mom Dad Parent ’s Email Address: Mom Dad Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian and other Pacific Islander White Ethnic Group: Hispanic Non-Hispanic Patient’s Primary Language : English ____ Spanish ____ Other ____________________ Parent’s/Legal Guardian’s Primary Language : English ____ Spanish ____ Other ________________ Does the parent/legal guardian require an interpreter? Yes No If there is insurance for child/children, please present the insurance card to the check-in staff. Emergency Contacts Mother’s Name (Last, First, Middle) Home # Work # Cell # Home Address (City, State, Zip Code) (if different from above) Father’s Name (Last, First, Middle ) Home # Work # Cell # Home Address (City, State, Zip Code) (if different from above) Additional Contact (Last, First, Middle) Home # Work # Cell # (Relationship to Patient) Home Address (City, State, Zip Code) Who may we thank for referring you to our practice? Birth Hospital Guarantor Information (Person financially responsible) Name Relationship to Patient Emancipated Minor? Yes No Street Address (If different from patient) City State Zip Date of Birth Home # Work # Cell # Employer Name City State Zip Insurance Information (if insurance is provided, please complete the information below) Insurance Name Claims Address Telephone # Subscriber ID # Group # Patient Relationship to Subscriber: Subscriber’s Name DOB: Subscriber Address (if different than guarantor) Subscriber Employer
Transcript
TCP-819 5/13 Thank you for choosing Texas Children’s Pediatrics
Date Completed
Primary Care Provider
Patient Registration Form (Please fill in all fields completely)
Patient Information
Child’s Full Legal Name (Last, First, Middle)
Date of Birth Sex
Preferred Name
Other Children in family:
Child’s Street Address (City, State, Zip Code) Telephone#where child lives Parent’s Work #
Mom
Dad
Parent’s Email Address:
Mom
Dad
Race: American Indian or Alaska Native Asian Black or African American
Native Hawaiian and other Pacific Islander White
Ethnic Group: Hispanic Non-Hispanic
Patient’s Primary Language: English ____ Spanish ____ Other ____________________
Parent’s/Legal Guardian’s Primary Language : English ____ Spanish ____ Other ________________
Does the parent/legal guardian require an interpreter? Yes No If there is insurance for child/children, please present the insurance card to the check-in staff.
Emergency Contacts
Mother’s Name (Last, First, Middle)
Home # Work # Cell #
Home Address (City, State, Zip Code) (if different from above)
Father’s Name (Last, First, Middle) Home # Work # Cell #
Home Address (City, State, Zip Code) (if different from above)
Additional Contact (Last, First, Middle)
Home # Work # Cell #
(Relationship to Patient)
Home Address (City, State, Zip Code)
Who may we thank for referring you to our practice?
Birth Hospital
Guarantor Information (Person financially responsible)
Name
Relationship to Patient Emancipated Minor? Yes No
Street Address (If different from patient)
City State Zip
Date of Birth
Home # Work # Cell #
Employer Name
City State Zip
Insurance Information (if insurance is provided, please complete the information below)
Insurance Name Claims Address
Telephone #
Subscriber ID #
Group # Patient Relationship to Subscriber:
Subscriber’s Name
DOB:
Subscriber Address (if different than guarantor) Subscriber Employer
Allergies: (Include name of medication or food, reaction, and age of onset) __________________________________________________________________________________ __________________________________________________________________________________ Current Problems: __________________________________________________________________________________ __________________________________________________________________________________
History: Birth History: Birth Length: ____________ Birth Weight:_____________________ Birth Head Circumference:______________ Discharge Weight: ________ Gestational Age at Birth (weeks):______ Delivery Method: Vaginal C-section If C-section, why? ______________________ APGAR scores: 1 min ____ 5 min _____ 10 min _____ Infant Feeding: Breast Bottle Both Formula name: _________________________ Hearing Screening: Pass Fail Re-testing Heart disease screening: Pass Fail
Medical History: (Check any that have been diagnosed and comment below)
Other Medical History: _________________________________________________________________________________ ____________________________________________________________________________________________________
Surgical History: _______No Surgeries
(Check any past surgeries and complete age/date and surgeon if known)
Procedure Date or Age Surgeon
Adenoidectomy
Appendectomy
Ear Tubes
Fundoplication
Gastrostomy Tube Placement
Heart Surgery
Hernia Repair
Orthopedic Surgery
Tonsillectomy
Urological Surgery
VP Shunt
Other Surgical History: _________________________________________________________________________________ ____________________________________________________________________________________________________
Family History: (Check any known problems in the family – please complete at least for parents and siblings)
Comments (including Other responses): _______________________________________________________________________ ________________________________________________________________________________________________________ Relationships: P=Paternal (father’s side of family), M=Maternal (mother’s side of family), GM=Grandmother, GF=Grandfather For example: MGM = Maternal Grandmother Additional Family History (if needed)
Home Environment: Number of People at Home:
______
Lives with biological parents: Yes No Foster Care: Yes No Primary Care Givers (circle): Parents Daycare Relatives Others:________________________ Daycare (hours/day): __________ Time at Relatives (hours/day): ______ Pets: Yes No Parent’s Status: Married Divorced Single Other__________ Mother’s Occupation: _____________________ Father’s Occupation: __________________________
Name Alive? No
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Father Y N
Siblings Bro Sis Y N
Bro Sis Y N
Bro Sis Y N
Bro Sis Y N
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MGF Y N
PGM Y N
PGF Y N
Relationship to CHILD
Name Alive? No
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Relationship to CHILD
Scanto:GenConsentTCPv2016
GeneralConsentforTreatment
Ihavevoluntarilypresentedformedicalcareandconsenttosuchmedicalcareandtreatmentincludingany diagnostic procedures and tests that the physician(s), his or her associates, assistants and otherhealthcare providers determine to be necessary. In the course of treatment, I understand andacknowledge that no warranty or guaranty has been or will be made as to the result or cure oftreatment.
I have the legal right to consent to medical treatment because I am the patient or I am theparent/guardian of the patient. All references to "patient", "me" and "my" in this documentmeans:_______________________________(nameofpatient).
ElectronicMedicalRecord
We share medical records electronically with other health care providers to allow and promotecontinuityofcareamongproviders. Ifyouvisitanotherproviderwhoalsoparticipates inanelectronicmedicalrecordsystem,theymayhaveaccesstoyourmedicalrecord.IfyoudonotwantmedicalrecordssharedwithotherproviderspleaserequestandcompleteaHealthInformationExchangeOpt-outform.
ElectronicPrescriptions(E-Prescribing)
I voluntarily authorize E-Prescribing for prescriptions, which allows health care providers toelectronically transmit prescriptions to the pharmacy of my choice, review pharmacy benefitinformationandmedicationdispensinghistoryaslongasaphysician/patientrelationshipexists.
TestinginEventofHealthcareWorkerExposure
Iunderstandthatintheeventthatahealthcareworkerisaccidentallyexposedtothepatient’sbloodorbodily fluids,orAIDS,pursuanttoTexas law, Iwillberequiredtohavebloodtestedtodeterminethepresence of Hepatitis B or C surface antigen and/or Human Immunodeficiency Syndrome (HIV)antibodies. Iunderstandthatthesetestsareperformedbywithdrawingasmallamountofbloodandusingsubstancestotesttheblood.
I understand that these test results will be kept confidential to the extent allowed by law and thatunauthorizeddistributionofthesetestresultsisacriminaloffenseunderstatelaw.
Acknowledgments
I acknowledge that administrative data, demographic information and other health informationdescribing patient care, services and outcomes are collected and used for healthcare operations,governmental and non-governmental reporting, and comparisons with other providers. In someinstances, performance data is aggregated and reported per physician. In every instance, we makeeveryreasonableefforttomaintainpatientandphysiciananonymity.
IacknowledgethatIhavereceivedaNoticeofPrivacyPractices("Notice").TheNoticeexplainshowwemayuseanddisclosethepatient’sprotectedhealthinformationfortreatment,paymentandhealthcareoperations purpose. "Protected health information"means the patient’s personal health informationfoundinthepatient’smedicalandbillingrecords.IfyouhavequestionsabouttheNotice,pleasecontactthePrivacyOfficeat(832)824-2091.
MyChart and MyChart Bedside Proxy/Release of Information FormCompleting this form allows access to portion of a patient’s health record (other than yourself) via the MyChart and MyChartBedside.
You may request proxy access if you are:·
the parent or legal guardian of a minor child under the age of 18, or·
a legally appointed guardian or healthcare decision maker for a patient over the age of 18·
MyChart Bedside Proxy allows access to portions of your minor child’s medical record during an inpatient admission at·
Texas Children's.I understand that Texas Children’s may loan me a tablet to use for MyChart Bedside to view patient health information·
during an inpatient stay.
In order to obtain proxy access to the MyChart account of a Texas Children’s patient, please complete all information below.
Parent/legal guardian information for proxy access:
Parent/guardian name: Parent/guardian DOB:
Previous name(s), if applicable: Have you been seen or treated at any Texas Children's facility?
Address: City: State: Zip:
Home Phone: Work Phone:
E-mail:
Proper ID must be provided and validated, which will be filed with this application. Please fax this form and proper ID toHealth Information Management (HIM) @ 832-825-0124.
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATIONI understand that by signing this authorization, I am providing Texas Children’s with documentation of my authorization·
to provide access to this patient’s protected health information through MyChart and MyChart Bedside.I am entitled to access the patient’s protected health information as his/her parent or legally appointed guardian.·
I am not a Foster Parent of the patient·
My rights to access to this patient’s protected health information have not been modified in any manner by any court of·
law.The documents I have provided in support of my right to access the patient’s protected health information, if any, are·
true and correct copies and are the most recent documents related to this matter.I understand that Texas Children’s reserves the sole right to determine whether proxy eligibility exists and to whom it will·
grant Proxy Access rights.I understand that this authorization must be filled out completely and signed and dated in order to be considered valid,·
and activation of the MyChart proxy access feature must occur within 60 days from the date of this authorization.
Signature of Patient/Authorized Person Authorized Person’s Authority to Sign Date(parent, guardian, power of attorney, etc.)
Patient information: (Patient to which proxy access is requested)
Patient Name: MRN:
Previous Name(s), if applicable: DOB:
Relationship to patient:
Parent Foster Parent Legal Guardian* Other** :
*Legal documentation is required (Examples include drivers license, passport, court order, etc.)**Route to HIM for processing via fax: 832-825-0124
Help with public health and safety issues. We may share health information about you for certain situations such
as: preventing disease; helping with product recalls; reporting births and deaths; reporting suspected abuse, neglect,
or domestic violence; reporting reactions to medications or product problems; or preventing or reducing a serious
threat to anyone’s health or safety. We may share portions of your health information with local, state, and/or federal
registry programs as required. We may share your health information for these activities in a limited data set, which
excludes some identifying information.
Do research. We may use or share your information for health research. We may share your health information for
these activities in a limited data set, which excludes some identifying information.
Comply with the law. We will share information about you if state or federal laws require it, including with the
Department of Health and Human Services if it wants to ensure we’re complying with federal privacy law.
Respond to organ and tissue donation requests. We may share health information about you with organ
procurement organizations.
Work with a medical Examiner or funeral director. We may share health information with a coroner, medical
examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests. We may use or share health
information about you: for workers' compensation claims; for law enforcement purposes or with a law enforcement
official or correctional institution; with health oversight agencies for activities authorized by law; or for special
government functions, such as military, national security, and presidential protective services.
Respond to lawsuits and legal actions. We may share health information about you in response to a court or
administrative order, or in response to a subpoena.
Schools (including Child-Care Facilities, Early Childhood Programs, Primary and Secondary Schools). We
may share your immunization records with a school with a verbal authorization sometimes.
Texas Children’s Responsibilities We are required by law to maintain the privacy and security of your oral, written, and electronic PHI. Texas Children’s
maintains policies and procedures intended to protect PHI maintained by Texas Children’s in any form. Workforce members
with access to your PHI receive privacy training which covers the how PHI can be used and disclosed and actions they must
take to safeguard your information. Our computer systems protect your electronic PHI at all times. We will let you know
promptly if an incident occurs that may have compromised the privacy or security of your information. We will not sell
your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We
will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we
can, you may change your mind at any time. Let us know in writing if you change your mind. An Authorization form and
Revocation of Authorization form are available on our website, http://www.texaschildrens.org, or by contacting the Texas
Children’s Privacy Office at (832) 824-2091.
Changes to This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice
will be available upon request, in our office and on our website at http://www.texaschildrens.org. This notice is effective
April 1, 2016.
Contact If you have any questions about this Notice or your privacy rights, or wish to obtain a form to exercise your rights as
described above, you may contact Texas Children’s Privacy Office at (832) 824-2091.
Thank you for choosing Texas Children’s Pediatrics Form 14 – September 2012
Written Acknowledgement of Receipt of Texas Children’s Hospital Integrated Delivery System Notice of Privacy Practices By signing below, you acknowledge receiving the Texas Children’s Hospital Integrated Delivery System (TCH IDS) Notice of Privacy Practices (Notice). The Notice explains how TCH IDS may use and disclose your protected health information for treatment, payment and healthcare operations purposes. Protected health information means your personal health information found in your medical and billing records. TCH IDS reserves the right to change the Notice from time to time. A copy of the current Notice or a summary of the current Notice will be posted at patient service locations throughout TCH IDS and on our website at texaschildrens.org. The effective date of the Notice will appear on the first page of the Notice or summary. In addition, each time you register or are admitted to any TCH IDS entity for treatment or healthcare services as an inpatient or outpatient, TCH IDS will have available for you, at your request, a copy of the current Notice in effect. Your signature below only acknowledges that you have received the Notice. If you have any questions about the Notice, please contact the TCH IDS Privacy Office. Contact information is located in the Notice.
Printed Name of Patient ____________________________________________________________________
Patient’s Date of Birth _____________________________________________________________________
Printed Name of Patient’s Representative ______________________________________________________
Relationship of Patient’s Representative _______________________________________________________
Signature of Patient or Patient’s Representative _________________________________________________
Date ___________________________________________________________________________________
WE at Texas Children’s Pediatrics (TCP) are committed to providing you with quality care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about this financial policy. You are personally responsible for payment of all charges that result from care provided by TCP, including any amounts not covered by your health plan. To assist us in establishing your TCP financial account, please:
• Supply all necessary information for the accurate billing of your claim, including your insurance card, employer information and demographic information. • Satisfy all insurance co-payments, deductibles and non-covered services on the day services are rendered. • Provide your insurance company and TCP with any additional information requested to complete the processing of claims filed on your behalf.
UNACCOMPANIED MINORS Minor must have an authorization for medical treatment signed by his/her parent/guardian and is responsible for providing current insurance information for self. Please note that co-payments and/or deductibles are expected at the time of service. REGARDING DIVORCE TCP does not get involved in disputes between divorced parents regarding financial responsibility for their child’s medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree or other arrangement places that obligation on your former spouse. REGARDING HEALTH PLANS AND INSURANCE For each visit to TCP, it is your responsibility to make sure TCP is currently under contract with your managed care plan. Verification of your coverage and benefits may be required. Often this verification requires us to share the reason for your visit with your managed care plan. If we are not contracted with your health plan, we may require full payment at the time of service. We will supply you with a copy of your itemized statement so that you can file for reimbursement from your health plan. Should your health plan require a more detailed description of services, please have them request it in writing. If you are referred to a specialist or decide you need a specialist, you may be required by your managed care plan to call your Primary Care Physician in order to obtain an insurance referral. It is your responsibility to obtain a referral before being seen by a specialist. If a referral is not obtained in advance, you may be held responsible for payment in full to the specialist. ASSIGNMENT OF BENEFITS In consideration of the services rendered or to be rendered by TCP, I hereby irrevocably assign, transfer and set over to TCP all right, title and interest in all benefits payable for the health care rendered by TCP to the patient(s), which benefits are provided in any and all insurance policies, employee benefit plans, re-insurance/stop loss contract and/or third party actions against any other person or entity, for whom my spouse, dependents or I are entitled to recover. I also hereby irrevocably assign, transfer and set over to TCP all right, title and interest in any and all claims, administrative appeals and causes of action against all insurance companies, employee benefit plans, re-insurance/stop loss carriers, third party administrators and/or other persons or entities responsible for the payment of health insurance benefits. I authorize my insurer, plan administrator, fiduciary and/or attorney to release to TCP any and all insurance policies, plan documents, summary plan descriptions, and/or settlement information upon written request of TCP or its attorneys in order to claim such medical benefits. I authorize payment to be made directly to TCP or my treating physician. I understand that there may be professional fees associated with the care provided by TCP billed separately by the person or organization who provided the services. In consideration of such services, I hereby irrevocably assign, transfer and set over to such persons or organizations all right, title and interest in all benefits payable for the health care rendered by TCP to the patient(s), which benefits are provided in any and all insurance policies, employee benefit plans, re-insurance/stop loss contract and/or third party actions against any other person or entity, for whom my spouse, dependents or I are entitled to recovered. RELEASE OF INFORMATION I agree to the release of any and all medical information, including HIV test results, and financial information necessary to process this and any future claims to my insurer or payer of health benefits, as I may designate that person or entity from time to time, for an indefinite period or until I submit a written revocation of this release. This consent to release and obtain information is valid until revoked and I may revoke this consent in writing at any time, except with regard to disclosures already made.
• As a service to our patients, TCP—or a third party with whom Texas Children’s contracts—provides courtesy appointment reminder calls/texts and possibly other important calls regarding financial obligations and/or healthcare related notifications such as well-check reminders and vaccine reminders. Such calls or texts may be placed using a prerecorded auto messaging system to the phone number provided to Texas Children’s. These messages are a free service from TCP, but your carrier may apply message and data rates. Opt-in consent is not required to receive services from TCP. Your initials confirm your consent to receiving such calls/texts at the telephone number you have provided to us. PLEASE INITIAL ______
• I have read and understand that I am personally responsible for payment on this account. PLEASE INITIAL______ • Medicaid: I do _________ or I do not _________ currently have Medicaid Insurance • I understand that this practice has a no show appointment fee of $25 dollars. I am responsible for paying the fee if I do not cancel an appointment with 24 hours’ notice. • I acknowledge that my provider may be participating in a shared savings program with my managed care plan. Information regarding any active program is
Print Name______________________________________________________ Guarantor Date of Birth: _________________________
E-mail_______________________________________________________ Relationship to Patient: ____________________________
Patient(s) Name: ______________________________________________ Date of Birth: _________________________________
With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
TEXAS VACCINES FOR CHILDREN (TVFC) PROGRAMPATIENT ELIGIBILITY SCREENING RECORD
A record of all children 18 years of age or younger who receive immunizations through the Texas Vaccines for Children Program must be kept in the health care provider’s office. The record may be completed by the parent, guardian, individual of record, or by the health care provider. TVFC eligibility screening must take place with each immunization visit to ensure the child’s eligibility status has not changed. This same record will satisfy the requirements for all subsequent vaccinations, as long as the child’s eligibility has not changed. If patient eligibility changes, a new form must be completed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccines under the TVFC Program.
(g) Has private insurance that covers vaccines:
Name of Insurer: Insurer Contact Number: ( ) Area Code + number
Policy/Subscriber Number: Group Number (if applicable):
Date of Screening:mm/dd/yyyy
Child’s Name:Last Name First Name MI
Child’s Date of Birth: Age: mm/dd/yyyy
Please check the first category that applies; check only one.
Parent/Guardian/Individual of Record:Last Name First Name MI
Provider’s Name/Clinic’s Name: Phone Number: ( )Area Code + number
NOTE: Knowingly falsifying information on this document constitutes fraud. By signing this form, I hereby attest that the above information is true and correct. I declare that the person named above is an authorized person and is eligible to receive TVFC vaccines.
Signature: Date:(mm/dd/yyyy)
CLINIC USE ONLY:TVFC Eligible:
Yes No
Screener’s Initials
Texas Department of State Health Services Stock No. C-10Immunization Branch Revised 03/2012
(c) Is an American Indian, or(d) Is an Alaskan Native, or(e) Does not have health insurance (uninsured), or
(b) Is a patient who receives benefits from the Children’s Health Insurance Plan (CHIP), or
CHIP Number: Date of Eligibility (mm/dd/yyyy)
(f) Is underinsured:1) has commercial (private) health insurance, but coverage does not include vaccines; or 2) insurance covers only selected vaccines (TVFC-eligible for non-covered vaccines only); or 3) insurance caps vaccine coverage at a certain amount. Once that coverage amount is reached, the child is categorized as underinsured.
(a) Is enrolled in Medicaid, or
Medicaid Number: Date of Eligibility (mm/dd/yyyy)
Con ciertas excepciones, tiene derecho a pedir y a ser informado sobre la información que el estado de Texas reúne sobre usted. Tiene derecho a recibir y examinar la información al pedirla. También tiene derecho a pedir a la agencia estatal que corrija cualquier información que se determine es incorrecta. Consulte http://www.dshs.state.tx.us para obtener más información sobre la notificación de privacidad. (Referencia: Código gubernamental, sección 552.021, 552.023, 559.003 y 559.004)
PROGRAMA DE VACUNAS PARA NIÑOS DE TEXAS (o TVFC)
REGISTRO DE DETERMINACIÓN DEL DERECHO A LA PARTICIPACIÓN DEL PACIENTE
Debe mantenerse el registro de todos los niños de 18 años de edad o menos que reciban inmunizaciones mediante el Programa de Vacunas para Niños de Texas en el consultorio del proveedor de salud. El registro lo puede rellenar el padre o madre, el tutor, el individuo que consta en el registro, o el proveedor de salud. La determinación del derecho a la participación del TVFC debe realizarse en cada consulta de inmunización para asegurarse de que el derecho a la participación del niño no ha cambiado. El mismo registro cumplirá con los requisitos de todas las vacunas posteriores, en tanto el derecho a la participación del niño no haya cambiado. Si cambia el derecho a la participación del paciente, debe rellenarse un nuevo formulario. Aunque la verificación de las respuestas no se requiere, es necesario quedarse con este registro, o uno similar, para cada niño que reciba vacunas bajo el Programa de TVFC.
Fecha de la determinación:(mm/dd/aaaa)
Nombre del niño: Apellido Primer nombre Inicial del 2.o nombre
Padre o madre, tutor o individuo que consta en el registro: Apellido Primer nombre Inicial del 2.o nombre
Marque la primera categoría que corresponda; marque sólo una.
Nombre del proveedor o de la clínica: Número telefónico:Código de área + el número( )
(a) Está inscrito en Medicaid, o
(c) Es indio americano, o(d) Es nativo de Alaska, o(e) No tiene seguro médico (no asegurado), o(f) Está subasegurado:
1) tiene seguro médico comercial (privado), pero la cobertura no incluye las vacunas; o 2) el seguro cubre sólo algunas vacunas (reúne los requisitos del TVFC sólo para las vacunas no cubiertas); o 3) el seguro limita la cobertura de las vacunas a cierta cantidad. Una vez alcanzada esa cantidad de cobertura, se
categorizará al niño como subasegurado.
NOTA: Falsificar información en este documento a sabiendas constituye un fraude. Al firmar este formulario, por este medio doy fe que la información es verdadera y correcta. Yo declaro que la persona nombrada arriba es una persona autorizada y reúne los requisitos para recibir vacunas del TVFC.
(g) Tiene seguro privado que cubre las vacunas:
Número del grupo (de ser aplicable):Número de póliza/suscriptor:
Firma: Fecha:(mm/dd/aaaa)
(b) Es paciente que recibe prestaciones del Plan de Seguro Médico Infantil (o CHIP), o bienNúmero de Medicaid: Fecha del derecho a la participación (mm/dd/aaaa)
Texas Department of State Health Services Stock No. C-10Immunization Branch Revised 03/2012
Número de CHIP: Fecha del derecho a la participación (mm/dd/aaaa)
PARA USO DE LA CLíNICA
CLINIC USE ONLY:TVFC Eligible: Yes No
Screener’s Initials
Nombre del asegurador: Número de contacto del asegurador:Código de área + el número( )
Fecha de nacimiento del niño: (mm/dd/aaaa)
Edad:
TEXAS DEPARTMENT OF STATE HEALTH SERVICES IMMUNIZATION REGISTRY (ImmTrac)
CONSENT FORM
(Please print clearly)
For Clinic/Office Use Child’s Last Name
Child’s First Name Child’s Middle Name
/ /
Child’s Date of Birth Child’s Gender: Male Female
Child’s Address
City
Mother’s First Name
ImmTrac, the Texas immunizatiimmunization registry is a secure arecords. With your consent, yourschools and other authorized promissed.
The Texas Department of Sta
I understand that, by granting the cunderstand that DSHS will includchild’s immunization information
• a public health district or loca• a physician, or other health c• a state agency having legal cu• a Texas school or child care f• a payor, currently authorized
I understand that I may withdrawinformation from the Registry at a– MC 1946, P.O. Box 149347, Au
By my signature below, I GRimmunization registry.
Parent, legal guardian or managing _______________________ Date
Privacy Notification: With few exceptions, yoreview the information upon request. You alsomore information on Privacy Notification. (Refer Questions? (800) 252-9152 • (512) 458Texas Department of State Health Servic
*Children under 18 years only.
Apartment # Telephone
State Zip Code County
Mother’s Maiden Name
on registry, is a free service of the Texas Department of State Health Services (DSHS). The nd confidential service that consolidates and stores your child’s (under 18 years of age) immunization
child’s immunization information will be included in ImmTrac. Doctors, public health departments, fessionals can access your child’s immunization history to ensure that important vaccines are not
te Health Services encourages your voluntary participation in the Texas immunization registry.
Consent for Registration of Child and Release of Immunization Records to Authorized Entities
onsent below, I am authorizing release of the child’s immunization information to DSHS and I further e this information in the state’s central immunization registry (“ImmTrac”). Once in ImmTrac, the may by law be accessed by: l health department, for public health purposes within their areas of jurisdiction;
are provider legally authorized to administer vaccines, for treating the child as a patient; stody of the child; acility in which the child is enrolled; by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. this consent to include information on my child in the ImmTrac Registry and my consent to release ny time by written communication to the Texas Department of State Health Services, ImmTrac Group stin, Texas 78714-9347.
ANT consent for registration. I wish to INCLUDE my child’s information in the Texas
conservator: ________________________________________________________________________ Printed Name
u have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for ence: Government Code, Section 552.021, 552.023, 559.003 and 559.004)
