Instructions for Completing

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1 Rock Hill Pediatric Associates Uncompromising Excellence. Commitment to Care. Dear Parents, It is very important that you contact your insurance company and inquire about your vaccine benefits. The state of South Carolina is transitioning to a Vaccine for Children (VFC) program effective July 1, Children will be eligible to receive VFC vaccine in our office if they meet the following criteria: Medicaid Enrolled American Indian or Alaskan Native Uninsured Insured patients may only receive vaccine supplied by the state of South Carolina if they meet the following eligibility requirements: Insured Hardship patient has a deductible greater than $ which has not been met and the family cannot afford to pay for privately purchased vaccine A child whose insurance caps vaccine coverage at a certain amount is eligible after the coverage amount is reached. The child is then considered to be in the underinsured category A child whose insurance does not include vaccines Children are not eligible for VFC or state supplied vaccine if they have health insurance that covers vaccines. This includes those with deductible plans that are less than $ If you feel that you meet the above eligibility requirements please make the staff aware prior to the administration of vaccines.. Sincerely, Rock Hill Pediatric Associates

2 SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL Patient Eligibility Screening Record Form Instructions for Completing Purpose: The purpose of the Patient Eligibility Screening Record Form is to provide a document, which can be used by DHEC and non-dhec Vaccines Assurance For All Children (VAFAC> providers, to record the patient s eligibility status to receive VAFAC vaccine. The completed form becomes part of the patient s record and is kept on file by the VAFAC provider. Item-By-Item Instructions: 1. Complete the Child s Name, Date of Birth and Provider. 2. Screen for eligibility at each visit by placing a check in the appropriate column. The child is SC VAFAC vaccine eligible if Medicaid, Uninsured, American Indian, Alaskan Native or Underinsured. If thechild is Insured, the child is NOT eligible for SC VAFAC vaccine. 3. Signature of the parent or guardian. 4. Enter the date of screening. Office Mechanics and Filing: 1. The Patient Eligibility Screening Record Form can be obtained by contacting the Immunization Division. 2. The completed Patient Eligibility Screening Record Form is filed in the child s medical record. SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

3 One patient per authorization form There may be a charge for record copies. I hereby authorize the use or disclosure of my identifiable health information as described below. I understand that if the organization authorized to receive the information is not an insurance company or health care provider, the released information may no longer be protected by federal privacy regulations. PURPOSE OF RELEASE: Ongoing Communication Copy of Record Legal or Insurance Review Authorized Representative s Request Other RELEASE FROM: Facility/Practice Name: Telephone #: Facility/Practice Address: Fax #: The facility/practice/individual listed above is authorized to release the requested health information for the following: date(s) of service, range of time or event(s): From: (MM/DD/YY) To: (MM/DD/YY) CHS-050 Rev. (2/05) Authorization for Release of Health Information The facility/practice/individual listed below is authorized to release the requested health information: CHECK THE SPECIFIC INFORMATION TO BE RELEASED: All Records & Details Discharge Summary Lab/Pathology Reports Appointment Information Emergency Room Records Medication Records Billing Information History & Physical Office/Clinic Notes Consultation Report Immunization Records Operative Report NAME OF PATIENT WHOSE INFORMATION IS TO BE RELEASED: Physician s Orders Progress Notes Psychiatric Evaluation Radiology/Imaging Reports Test Results This information may be released to and used by the following individuals/organizations. A separate authorization must be completed if the information being released or the purpose differs between the individuals/organizations listed below: Name Address Telephone/Fax # Relationship For Carolinas HealthCare System Use Only: CHS Employees Please Complete Other (Please Specify) I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, sickle cell anemia, psychological or psychiatric impairments, sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC) and/or human immunodeficiency virus (HIV). Patient Name: First Middle/Maiden Last Patient Address: (Street Address/PO Box, City, State, Zip) Social Security #: Date of Birth: Medical Record/Chart # Please provide phone numbers where you are authorizing CHS to leave patient information as described above: Home: Work: Cell: RELEASE TO: PATIENT S RIGHTS AND SIGNATURE: I understand that I have a right to revoke this authorization at any time by notifying the Medical Record Department of the above named organization in writing. (I understand that revocation will not apply to information that has already been released in response to this authorization. I understand that revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.) I understand that authorizing the disclosure of this private health information is voluntary and I can refuse to sign this authorization. I understand that I may request to obtain a copy of the information to be used or disclosed per CHS Notice of Privacy Practices/Policy. This authorization will expire when the information from the event/purpose noted above is released to the recipient named in this document. If the patient is a minor or is clinically unable to sign, an authorized representative may sign this authorization. PRINT NAME (Patient/Authorized Representative): SIGNATURE: DATE: If Authorized Representative, please indicate relationship to patient: MINOR S SIGNATURE: Spouse Parent Guardian Executor of Estate Power of Attorney Please note, if the information is relating to the treatment of pregnancy, drug and/or alcohol abuse, venereal disease, or emotional disturbance for a patient under the age of of 18, the patient must also sign this authorization. NAME OF MINOR: SIGNATURE OF MINOR: DATE: FINANCIAL COMPENSATION: If the requestor of patient information is a health care provider, will the health care provider receive any financial compensation in exchange for using or disclosing the health information described above? Yes No N/A Identification verified Copy of Authorization given to patient Date of release: via Mail Fax Other Accepted - Released information as described above Partially Accepted - Describe patient information not released: Employee Name & Title Employee Signature: Date: Job: CG4455 9th Proof: 2/23/05 Ink: Black Paper: 20# White

4 Un Paciente Por Formulario de Autorización Podría Haber un Costo por Copias de Historiales Carolinas HealthCare System - Authorization for Release of Health Information Form Carolinas HealthCare System Formulario de Autorización para Dar a Conocer Información de Salud Por medio del presente, autorizo el uso o la revelación de mi información de salud identificable como es descrito abajo. Entiendo que si la organización autorizada a recibir la información no es una compañía de seguro o un proveedor de salud, la información entregada podría ya no ser protegida por las regulaciones federales de privacidad. PROPÓSITO DE LA ENTREGA: Comunicación en Curso Copia del Historial Revisión Legal o del Seguro Solicitación de un Representante Autorizado Otro ENTREGA POR PARTE DE: La instalación/consultorio/individuo anotado abajo está autorizado a entregar la información de salud solicitada: Nombre de la instalación/consultorio: Número Telefónico Dirección de la instalación/consultorio: Número de Fax La instalación/consultorio/individuo anotado arriba está autorizado a entregar la información de salud por lo siguiente: fecha(s) del servicio, margen de tiempo o evento(s): Desde:(mes/día/año) Hasta:(mes/día/año) MARQUE LA INFORMACIÓN ESPECÍFICA A SER ENTREGADA: Ordenes del Doctor Otros (Por favor, especifíque) Todos los Historiales y Detalles Resumen del Alta Reportes de Laboratorio/Patología Notas de Progreso Información de Citas Historiales de la Sala de Emergencia Registro de Medicamentos Evaluación Previa Psiquiátrica Información de Cobros Historial y Examen Físico Notas de Oficina/Clínica Radiología/Reportes de Imágenes Reporte de la Consulta Registro de Vacunas Reporte Operatorio Resultados de Pruebas Entiendo que la información en mi historial médico puede incluir información relacionada a tratamiento de abuso de droga o alcohol, anemia de células falciformes, insuficiencia psicológica o psiquiátrica, enfermedades por transmisión sexual, síndrome de inmunodeficiencia adquirida (SIDA), complejo relacionado al SIDA y/o otros virus de la inmunodeficiencia humana (VIH). NOMBRE DEL PACIENTE CUYA INFORMACIÓN SERÁ ENTREGADA: Nombre del Paciente: Primer Segundo/De Soltera Apellido Dirección del Paciente: (Dirección de Calle/Apdo. Postal, Ciudad, Estado, Código Postal) Número de Seguro Social: Fecha de Nacimiento: Número de Historial/Hoja Médica Por favor, provea los números telefónicos donde usted está autorizando a CHS a dejar la información del paciente descrita arriba: Casa: Trabajo: Celular: ENTREGAR A: Esta información puede ser entregada a y usada por los siguientes individuos/organizaciones. Una autorización aparte debe ser completada si la información entregada o el propósito difieren entre los individuos/organizaciones anotados abajo: Nombre Dirección Número Telefónico/Fax Parentesco/Relación DERECHOS Y FIRMA DEL PACIENTE: Entiendo que tengo el derecho de revocar esta autorización en cualquier momento al notificar por escrito al Departamento de Registros Médicos ( Medical Record Department ) de la organización mencionada arriba. (Entiendo que la revocación no se aplicará a la información que ya ha sido entregada en respuesta a esta autorización. Entiendo que una revocación no se aplicará a mi compañía de seguro cuando la ley le otorga el derecho de impugnar un reclamo bajo mi póliza.) Entiendo que autorizar la revelación de esta información de salud privada es voluntario y puedo rehusarme a firmar esta autorización. Entiendo, según el CHS Anuncio de Cómo Manejamos la Privacidad, que puedo solicitar inspeccionar u obtener una copia de la información a ser usada o revelada. Esta autorización se vencerá cuando la información del evento/propósito anotado arriba es entregada al destinatario nombrado en este documento. Si el paciente es menor de edad o es incapaz clínicamente de firmar, un representante autorizado puede firmar esta autorización. NOMBRE EN LETRA DE IMPRENTA (Paciente/Representante Autorizado): FIRMA: FECHA: Si la firma es de un Representante Autorizado, por favor, indique su parentesco/relación: Esposo/a Padre/Madre Guardián Testamentario Apoderado FIRMA DEL MENOR DE EDAD: Por favor, tome nota, si la información es relacionada al tratamiento de un embarazo, abuso de droga y/o alcohol, enfermedad venérea, o trastorno emocional para un paciente menor de 18 años de edad, el paciente debe también firmar esta autorización. NOMBRE DEL MENOR: FIRMA DEL MENOR: FECHA: COMPENSACIÓN FINANCIERA: Si el solicitante de la información es un proveedor de cuidado de salud, recibirá él alguna compensación financiera a cambio del uso o revelación de la información descrita arriba? Sí No No se aplica For FOR Carolinas CAROLINAS HealthCare HEALTHCARE SYSTEM SystemUSE Use ON Only: LY: CHS EMPLOYEES Employees PLEASE Please COMPLETE Complete Identification verified Copy of Authorization given to patient / Date of release: via Mail Fax Other Accepted - Released information as described above Partially Accepted - Describe patient information not released: CHS Employee Name & Title: CHS Employee Signature: Date Rev. 1/18/05 PFS 1/05 AR, GH, CG

5 Relacion al Paciente: Mismo / I * Carolinas Physicians Network ACKNOWLEDGEMENT FORM Patient s Name: Medical Records # Date of Birth Day Month / Year We are required by law to provide you with our Notice of Privacy Practices which explain how we use and disclose your health information. We are also required to obtain your signature acknowledging that this notice has been made available to you. Signature: (Patient or Authorized Representative) Date: Relationship to Patient: Self Reason Patient Unable/Unwilling to Sign: Spouse Other ACKNOWLEDGEMENT FORM DOCUMENTO DE RECONOCIMIENTO DE CAROLINAS PHYSICANS NETWORK Nombre del Paciente Numero de Registro Medico Fecha de Nacimiento Dia Mes / Ano La ley nos requiere que nosotros le proveamos a usted con nuestro Aviso de Practicas de Privacidad las cuales explican como podemos usar y divulgar su informacion medica. La ley tambien nos requiere que obtengamos su firma, reconociendo que este aviso lo hemos hecho disponible para usted. Firma: (Paciente o Representante Autorizado) Fecha: Esposo (a) Otro Razon Por la Cual El Paciente No Puede/No Desea Firmar: CHS-052-2HP (12/08)

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8 South Carolina STATE Vaccine Program: Insured Eligibility Form Child s Name: Date of Birth: Insurance Company Policy Number Name and Insurance ID Number of Policy Holder Insured STATE Vaccine Eligibility Categories HPV vaccine is excluded from the STATE Vaccine Program. Check appropriate box(es) regarding eligibility for STATE vaccine, as applicable: Non FQHC/Non RHC Providers*: Insured but coverage does not include vaccines (Underinsured); Insured but coverage only for select vaccines (eligible for STATE vaccine for non-covered vaccines only) (Underinsured); Insured but coverage capped at certain amount and cap has been exceeded (Underinsured) *FQHC s and RHC s screen the Underinsured category with SC VFC Patient Eligibility Screening Record Form (DHEC 1146) All Providers: (This section includes all providers enrolled in the STATE Vaccine Program) Health insurance deductible > $ per child OR > $ per family (Eligible for STATE vaccine only if the deductible has not been met and the family cannot afford to pay for vaccine) (Insured Hardship). Effective 01/25/2013 through 06/30/2013, Insured children without access to private influenza vaccine. NOTE: Children who are not eligible for VFC or STATE vaccine programs must be administered privately purchased vaccine. I hereby acknowledge that the information given herein is true and correct. I authorize DHEC to verify any information contained in this document. Signature of Patient/Parent/Guardian Date Signature of Healthcare Provider/Designated Staff Date DHEC 1231 (Rev. 1/2013) South Carolina Department of Health and Environmental Control

9 SC VFC Patient Eligibility Screening Record Form Child s Name: (Patient label may be used) Provider: Last Name First Name MI Date of Birth: FQHC RHC DHEC A record must be kept by the healthcare provider that reflects the status of each child <19 years of age who receives immunizations by a VFC Provider. Eligibility Screening Status (Referring to the key below, select one eligibility screening status per entry) Medicaid Uninsured American Indian or Alaskan Native Underinsured 1 (Eligible for VFC vaccine at FQHC/ RHC or DHEC only) Insured 2 (Not eligible for VFC vaccine) Date of Screening Signature of Parent/Guardian/Individual of Record By signing below, you are affirming that all information you have provided regarding Medicaid or other insurance is true and accurate. 1 Underinsured: A child who has commercial (private) health insurance but the coverage does not include vaccines, a child whose insurance covers only selected vaccines (i.e., Insurance does not cover vaccine to be administered making the child VFC-eligible for noncovered vaccines only), or a child whose insurance caps vaccine coverage at a certain amount. Once that coverage amount is reached, the child is categorized as underinsured. Underinsured children must only receive VFC vaccine in an FQHC, RHC, or DHEC clinic. 2 Insured: A child who has commercial (private) health insurance that includes coverage for vaccines. A child is considered fully insured even if a deductible has not yet been met and a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier (high-deductible policy) or the parent must share in the cost of the vaccine(s) (e.g., co-pay or coinsurance). DHEC 1146 (Rev. 3/2011) SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

10 V e. e. e e t a ti.1 ac,iç.. I &m C num.nta. Got Rock Hill Pediatric Associates twrorc 00 I.tp_.e it a t ca4 us to schedule an appointment for wet visits gn s!ck vicits such as Fe,er t.r Fating Hot Rashes old For questions about your care after hours, call our nurse triage line 24 hours a day at or to schedule 1 (Rock Hill) or (Fort Mill) 0 Call our Live Answer staff to make an appointment at p.m., and Sunday 1 p m.-4 p.m. 0 Our Fort Mill practice is also open during the weekendl Saturday 9 a.m.-1 onto the Rock Hill Pediatrics website 0 Our Fort Mill practice is open 8:30 a.m.-8:00 p.m. Monday through Friday. 0 Our Rock Hill practice is open 8:30 a.m-5:00 p.m. Monday through Friday. 0 You can also schedule an appointment online, using MyHealth Online 1 Log bib YOU KNOW? V y a aa S e n

11 race and ethnicity on our patients. Please check the appropriate box below. Race: (Ancestral/genetic lineage with which you associate yourself) In order to comply with federal government regulations*, it is necessary that we capture [his form is. far dais. coikcr.ion ourpacea and is. not port of the permanent medical record. ii can vera and k.ein estrncnt Act ot ij.9 imeanngpai Use) F1 Ot.her El c. Lanitussite D Japanese []Korear El I aotmn El Pormgueae [] Rorsian El Spanish El Vtetnarnese inngnsn U orraoic U Liulese LU OSCOCfl U oennan tirnong U Irasi.a.n Unknown Person i5 trn.abie or unwi..llin to i.esoonct Other perec n abe does rot a1hliate inert race v r o he her iaed rant a I L L Is lander Hawaiian/ Pacific Origin in any of the originalpeopies of Hawaii, Guam, Samoa, or other Pacific Islands. * am of the in inal eo les of ethe fcidle Fast or rra frrc 4dViemaml subcontinent, including, for example, Cambodia, China, india, Japan, Korea, Malaysia, African American ni of the black racial rou sof Africa Asian Origin in any of the original peoples of the Par East, Southeast Asia, or the Indian Multiracial Don o a combasation of more than one of the tsted races. Person is unwihir g to answer ethnicity question. []Non Hispanic Person ts not of Hispanic or Latino ethnicity Person of Cuban, Mexican, Puerto Rican, South or Central.Amedcan, or other Spanish culture or origin, Ethnic Odgin [1 Other []Unknown []Decline r] Hawaiian/Pacific Islander El Multiracial []Native American [] Black or Afncan American [j Asian []Caucasian CAROLINAS HEALTHCARE SYSTEM

12 Ainenc an Atademy of Pediatrics at the time of this and future health ss hich are recoinniended by the Center tin Disease Control (i)c) and the (wish tormychild -,torti.eit all 4atcincs t:... 1 t r t I ci ici It di r. le2al guardian. This oii cnt is saud for all futuie snits unless it is rescinded by pan-nt n administration and that T hase opportunity for anyol my questioim to be discussed prior to immunizations irarniuiization %i ill be made a ailable to me prior to each 4 accine I undeistand that %accine Information Sheds pro ided by the ( DC lot each entry. ma It. coinniend taccines which are not required for school or day care maintenance visits at Rock lull Pediatric Associates (he CL)C and AP CONSENT FOR IMMUNIZATIONS

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