Application for Services

The following is our Application for Service form. Please fill out the form completely to avoid delays.

Name *

First

Middle

Last

Email *

Cell Phone

Home Phone

Ethnicity

Gender

Female
Male

Age

Date of Birth

State

Address

Address Line 1

Address Line 2

City

State

Zip Code

Identification Validation and Insurance

Social Security #

Drivers License #

State

Health Insurance Company

Insurance Policy #

Parent and School

Grade

School Name

Parent Name

Friend

Relationship

Parent Phone

Health Care Integrated Services is my provider of choice.

I understand if I am 12 years or older, I can consent to certain confidential medical services. I authorize the release of any information necessary to assist the Agency in processing and in resolving any issues or claims that may arise. I hereby consent to all medical and other services provided by HCIS and I release the Agency from any bodily injury or liability resulting from these services.

Client declines any third party contact regarding HCIS treatment services.

Parent or Guardian:

By typing my name in the box above, I hereby consent to services.

Date

The following section is for patients 12 and over

Patient

By typing my name in the box above, I hereby consent to services.

Date

A Patient copy of this release is as valid as the original

By law, parental consent is not required for the conduct of mandated screenings, the application of first aid treatment, prenatal care, services related to sexual behavior and pregnancy prevention and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students who are 18 years or older or for students who are parents or legally emancipated. My digital signature indicates I have received a copy of the Notice of Privacy Practices.

This information is confidential and privileged in accordance with CFR and HIPPA Regulations. If you are not named above as addressee, it may be unlawful for you to read, copy distribute or otherwise use the information on this webpage. Misuse of this information is subject to prosecution. Copyright 2017 HCIS.

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