A Pediatric Clinic ThatOffers Affordable Health Care Services
I understand that CARIN’ CLINIC may not be able to fulfill all the health needs that my child may have. If s/he requires services that CARIN’ CLINIC cannot provide, appropriate referrals will be made. I authorize CARIN’ CLINIC staff to provide care for my child. This care/service may include:
Age appropriate well-child exams consisting of a comprehensive health history, complete physical assessment, screening procedures, and anticipatory guidance.
Diagnosis and treatment of acute illness and injury
Management and monitoring of stable chronic conditions
Basic laboratory services on site
Ability to prescribe or dispense medications, in accordance with medical and pharmacy practice acts
Patient health education and anticipatory guidance for students and parents
Mental health services
Services are provided by certified pediatric nurse practitioners. All volunteers (nurses, doctors, staff) are covered by the Volunteer Service Act, CO Revised Statute 13-21-115.5. CARIN’ CLINIC does not provide the following services: x-rays, hospitalization, emergency care for life threatening conditions, long-term treatment of mental health problems, or treatment of complex medical or psychiatric conditions.
I authorize the release of written and verbal information pertinent to my son/daughter’s medical records to other health care providers as designated by me whenever necessary for my child’s care. This includes release of medication/prescription history from pharmacies and other health care providers.
I authorize the release of written and verbal information pertinent to my son/daughter’s health care between my child’s school counseling and health staff, and CARIN’ CLINIC, whenever necessary and appropriate for his/her care. I further give consent to CARIN’ CLINIC staff to examine my son/daughter’s school records for information that is necessary and appropriate to assist the staff in helping my child.
I authorize CARIN’ CLINIC to release information regarding treatment to third party users, such as Medicaid or others, for the purpose of billing and for any reason in accordance with acceptable medical practice pursuant to the law.
It is my responsibility as the parent to notify the clinic about changes in guardianship. I have read and completed this consent form to the best of my ability. I understand that I may call CARIN’ CLINIC with any questions that I may have.
I have read Notice of Privacy Practices on website and know that I can request a copy at the clinic:
Typing you name is the same as your signature.
Patient Eligibility Screening Record
Vaccines for Children Program (VFC)
5150 Allison Street, Arvada, CO 80002
My child qualifies for vaccines through the VFC program because he or she:
Mi hijo califica para vacunas a través del programa VFC porque:
Does not currently have health insurance
No tiene seguro médico
Has CHP+ or private insurance
Tiene CHP+ o seguro privado
Nombre del paciente
Date of Birth
Fecha de nacimiento
Signature of Parent/Guardian
Firma del Madre/Padre
Fecha de hoy
A record must be kept in the healthcare provider’s office that reflects the status of all children 18 years of age or younger who receive immunizations through the VFC program. The record may be completed by the parent, guardian, individual of record, or by the healthcare provider. This same record may be used for all subsequent visits as long as the child’s eligibility status has not changed. While verification of responses is not required, it is necessary to retain this record for each child receiving vaccines.
Financial Review Form
Total Number of Persons Living in the Household: Please enter information...
Current Pay: $ Please enter information... every:
Spouse’s Current Pay: $ Please enter information... every:
By signing below, you state that the information presented is true and accurate to the best of your knowledge. Also, you will notify Carin’ Clinic if significant changes occur in your household income and/or living situation.
For Carin’ Clinic Staff
Nombre del hijo
Nombre de Padre/Madre
Total Number of Persons Living in the Household:
Total número de personas que viven en el hogarPlease enter information...
Es usted empleado actualmente:
Actual paga de esposo:
Situación de la vida:
Al firmar abajo, estado que la información presentada es verdadera y exacta a lo mejor de su conocimiento. Asimismo, le notificará clínica Carin' producirse cambios significativos en su ingreso o situación de vida.
Firma del padre
Acknowledgement of Receipt of Notice of Privacy Practices
Carin’ Clinic 5150 Allison Street
Arvada, CO 80002
Privacy Officer: Edwina Quintana 303-423-8836
I hereby acknowledge that I have access to a copy of this medical practice's Notice of Privacy Practices via their website. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment.
***PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR CHILD’S HEALTH INFORMATION AND PERMISSION TO BRING YOUR CHILD TO THE CLINIC FOR TREATMENT***:
(This includes step-parents, grandparents and any care takers who can have access to this patient’s records, and who has permission to bring child to clinic):
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