Dear Parent or Guardian:
Aaron E. Henry Community Health Services Center, Inc. (AEHCHC) will be providing Early Periodic Screening, Diagnosis and Treatment (EPSDT).
Medical and dental services for children and adolescents are offered through our school-based clinics, which include:
- Complete Physical Assessments, Wellness Exams, & Sports Physicals
- Vision Screening
- Hearing Screening
- Dental Assessment, Treatment, and Referral
- Developmental Assessments, Evaluations, and Referral for Treatment
- Parent and Child Health Education
- Referral Services
Would you like your child to be assessed by Aaron E. Henry Community Health Services Center, Inc.?
Does your child need an interpreter?
Emergency Contact Name
Family Health History: To the best of your knowledge, does anyone in your child’s family have the following conditions? (Check which applies)
Child's Health History: Does your child have the following: (Check which applies)
All physicals in the schools are unclothed, appropriately draped with clinic gown and with a chaperone present. Do you consent to an unclothed exam?
Lead Poisoning Risk Assessment. Answer ONLY IF YOUR CHILD IS 6 YEARS OLD OR YOUNGER. Check each box for YES or check NONE (if the answer is NO for all).
List all the people who live in your household. To add one person, click the "Add Person" button. To remove one person, click the "Remove Person" button.
I, the patient or parent/guardian, hereby authorize any holder of information about me or any information needed for settlement of claims to be released to Medicaid, Medicare, or Insurance Provider. I understand approved claims will be deducted from my allocated benefits whether they were rendered in one pf our clinics or mobile health family.
I request that all health insurance benefit payments be made on my behalf to Aaron E. Henry Health Services Center, Inc.. Having registered with AEHCHC, I, the undersigned patient or responsible person, understand that this registration form is valid and services will continue as long as I or my child is enrolled in this school or until I decide to opt-out by sending a written notice to discontinue services.
My signature is my authorization to bill on my behalf. My signature also serves as authorization for service and treatment. I may provide a written notice to dismiss this authorization to AEHCHC at any time.
By electronically signing your signature, you are agreeing that you have read and understood the above and consent to submit your application electronically.