Section I: - Crow Creek Sioux Tribal Elementary School



CROW CREEK TRIBAL SCHOOLSDormitory Application2018-2019CCTS Residential Program State of PurposeThe Purpose of the CCTS Dorm is to provide a traditional home-living environment to students attending Crow Creek Tribal Schools. We are not a therapeutic dormitory, so we may not be able to meet the need of all students. All student applications will be reviewed by the dormitory committee to determine if the CCTS residential program can meet each student’ residential needs. A waiting list will be as application come in to the CCTS Dorms for the new school year.Attendance in the DormsBecause we only have space for 50 girls and 50 boys in the new dorms, we want to keep our attendance high throughout the entire year. We hope that the students and their parent/guardian will make a strong effort to be with us for the entire school year once they are accepted. Whenever a student is out of the dorm for 10 consecutive days, they will be dropped from the dorm (as required by BIE) and their name will be placed at the bottom of the waiting list. The next person on the waiting list will be contacted and invited into the dorms. We appreciate your understanding and look forward to providing a safe and enjoyable residential experience the 2017-2018 school year.Other Notes:Be sure to have your CHECK-OUT FORM NOTARIZED.Health forms are important to fill out (both off-reservation and local students)Crow Creek Tribal Schools 2018-2019 Dormitory Application105 Chieftain Loop, Stephan, SD 57346Appendix B-Charges for Damages caused by studentsThe following are amounts which could be charged in the event you son/daughter was to cause damage to the dorm either by intention or as a result of misconduct.Damage to dorm cause by student:Broken Window $100Hole punch in wall $50Door $300Wardrobe/Hasp Damage $50Combination lock $15-$25 Graffiti Clean-up $25Fire Extinguisher Cover $75Bathroom/Shower Damage $100Damage to furniture, causing replacement values to be considered: (freight might also be charged). These prices are based on the actual costs of furniture as ordered by BIA.Wardrobes $485Bed $295Mattress $140Drawer $140Desk $295Chair $125Nightstand $310Desk/Chair $165Table $385Stool $30Foosball Table $530Round Table $320Coffee Table $180End Table $180Bookcase $120Table w/Ped & Footrest $365Pool Table $4,400Lounge Table $320I understand that if my son/daughter damages any dorm property, I will be included in the discussion and investigation. I also agree that should my son/daughter be found liable through either misconduct or willful actions, I will be responsible for any reasonable charges, which might include freight.___________________________________________________________________________________________Student’s NameStudent’s Signature___________________________________________________________________________________________Parent/Guardian SignatureDateElementary School/Better Alternative/Middle School/High School101 Crow Creek LoopStephan, S.D. 57346CROW CREEK TRIBAL SCHOOLS390525267970: 605-852-2455/605-852-22581-800-370-7908Fax:Administration 605-852-2669High School 605-852-2401 Middle School 605-852-2573ATTENTION*****PLEASE TAKE NOTICE*****Parents & Guardians,Dorm allow students in Grade 7-12. ALL NEW incoming freshman students MUST have PHYSICALS for sports and/or DORMITORY. Please get physicals appointments for sports BEFORE school begins. ALL DORM students need Physicals & Notifications of ANY MEDS they are on OR have been on in the past.IMMUNIZATIONS need to be up to date.A permission slip must be signed for FLU SHOTS for this upcoming school year. Middle School Students GRADE 6-8 need physicals for sports and/or dorm. ANY HEALTH ISSUES OR ALLERGIES must be reported by calling the nurse or the Dormitory Supervisor at 605-852-2258 Ext. 3125. IF AT ANY TIME YOUR MAILING ADDRESS, PHONE NUMBER OR YOU MOVE (EVEN TEMPORARILY) YOU NEED TO NOTIFY THE SCHOOL WITH THIS INFORMATION.Thank YouHome Living SpecialistDorm SupervisorCrow Creek Tribal Schools Dorm Application Packet for Students 6/13/11{The Home Living Specialist will call each parent/guardian to review, prior to approval.}Failure to provide an accurate response to all questions can result in denial of application.Section I: Educational HistoryStudent Name: ___________________________________________________Date: ____________________Parent/Guardian: ___________________________________. Relationship to student: __________________Phone #s: Home ____________________ Cell _____________________ Work ____________________Other phone #s for emergencies: _____________________; __________________________.Mailing Address: ______________________________________ City _____________________ State ______Check boxes below to indicate previous and current educational placements, if known.Kind of Placement (check all that apply)PreviousMost recentRegular ClassroomRegular Classroom with in-class support and/or accommodationsSpecial Education Classroom/Resource RoomAlternative SchoolTreatment ProgramResidential School and DormHome and/or Hospital-based InstructionNot in school – suspendedNot in school – expelledPlease describe educational placement(s) checked above:Section II: Living Situation History Check boxes to indicate previous and current living situations, if known.Type (check all that apply)Previous(Before)Current(Now)One Parent (indicate Mother or Father):RelativesFoster CareGroup HomeEmergency ShelterResidential Treatment (non drug/alcohol)Drug/Alcohol Residential Treatment ProgramMedical HospitalPsychiatric HospitalJuvenile Center (JDC)Correctional Facility (i.e. Custer)Has a child Has fathered a child or been pregnantCrow Creek Tribal Schools – Dorm Application Packet for StudentsSection III: Behavioral Issues Student’s Name: _______________________________________________Date: ___________________Note to Parents/Guardians: Your providing accurate information will help us provide your child with the best possible services to help her/him have a successful year in our dorm. Has the child or youth ever exhibited any of the behaviors listed below? If yes, check those that apply. Shows strong emotions Impulsive Stealing Extreme sadness Anxiety Depression Runs away Mood changes Hard time sleeping Eating disorder Hyperactivity Bladder/bowel problems Not accepting authority Refusal to accept limits Argues with others Verbal aggression Self-injurious behavior Persistent school refusal Anger towards self Anger towards others Cutting Expressed aggression towards people Expressed aggression towards property Tends to avoid social contact with others Expressed thoughts of suicide Shown suicidal behavior Suicidal attempts A family member or very close friend has committed suicide Has a social services case worker Extreme withdrawal from family Serious sleep disturbance Fire setting/fire play Animal cruelty Problems with the law Missed more than 10 days of school last year Suspension (out of school) during past year Expelled from school during the past two years Huffing inhalants (paint, hairspray, glue, nail polish) Huffing “dusters” (aerosol air cleaners - to clean key-boards, etc.) Huffing alcohol-based products or other aerosol-type products Substance abuse Experienced trauma Inappropriate behavior Has been arrested Has a probation officer Bullying Special concerns or counseling help you would like to see for your child: (please list)New Policy for all dorm students-2017-18 School Year: For your child’s safety parents/guardians must agree with allowing the dorms to test their child for mood altering substances if there is reason for concern. In this cause you will be notifies of the reasons for this concern and the testing results.I give my permission for my son/daughter to be tested. I understand this is for their safety, and that of the dorms. I also understand that I will be contacted both before and after this testing.Signature of Parent/Guardian:____________________________________________________________________________Crow Creek Tribal Schools – Dorm Application Packet for StudentsSection IV: Social History – Counseling InformationStudent’s Name: __________________________________________Date: _________[Failure to provide an accurate response to questions can result in denial of application or your child’s immediate release from the CCTS Dorms.]Has your child received any out-patient counseling or therapy for substance abuse, mental health or behavioral issues? _____Yes _____No If yes, please identify and describe what kind and have the Counselor or therapist send a report and recommendations to the Dorm Counselor, Crow Creek Tribal Schools Dorms.Why did they seek counseling? _______________________________________________________________Name & Title of Counselor or Therapist: ____________________________________________________________________________________________________Address: _________________________________________________________________________________________Phone Number: ______________________ Date(s) of Counseling: _______________________________Has your child ever received in-patient services treatment program for substance abuse, mental health or behavioral issues? ______ Yes _____ NoIf yes, please have the treatment program send a report and aftercare recommendations to the Dorm Counselor, Crow Creek Tribal Schools Dorms.Did they complete this? ____ Yes ____ Nowas this helpful? ____ Yes ____ NoName of Treatment Program: __________________________________________________________________________________________________Address: ______________________________________________________________________________________Phone Number: ________________________________ Date of Treatment: ________________________Has your child ever been arrested? _____ Yes _____ No Has your child ever received services from a correctional program? ____ Yes ____ NoIf yes, explain. _________________________________________________________________________________Please have the facility send a report & recommendations to the CCTS Dorm Counselor.Name of Correctional Facility: ___________________________________________________________________________________________________Address: ___________________________________________________________________________________________________Phone Number: ________________________________ Date of admittance: _________________________Does your child have a Social Worker or Probation officer? If so, please provide name and contact information. ___________________________________________________________________________________________________Has your child ever been arrested or charged with a sexual offense? ____Yes ____NoHas your child ever been a victim of sexual abuse? _____Yes _____NoIf yes for either, please describe: __________________________________________________________________________________________________________________________________________________________________________________________________________If yes, has your child/youth been in counseling? ____ Yes ____ NoSection IV: Social History, Continued. Student’s Name: __________________________Has your child displayed any anger against others or themselves? ____ Yes ____ NoIf yes, please explain. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________Does your child use “cutting” as a way to solve problems? _____ Yes _____ No If yes, please explain.________________________________________________________________________________________________________________________________________________________________________________________________________What is the cutting behavior? (i.e. possibly using a razor to cut their arms.)_____________________________________________________________________________________Has your child missed more than ten days of school during the past school year? _____ Yes _____ No If yes, please explain: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________Has your child been expelled during the past school year? _____ Yes _____ No If yes, please explain: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________Has your child received an out-of-school suspension during the last school year? If yes, please explain: __________________________________________________________________________________________________ __________________________________________________________________________________________________Do you have any special concerns for which you would like the counselor to be aware? __________________________________________________________________________________________________List any medications your child has been prescribed during the past year:Name of medication(s)DosageHow often taken? _____________________________________________________________________________________Parent/Guardian (print)Signature of Parent/GuardianDateCrow Creek Tribal SchoolsSCHOOL/I.H.S. COUNSELING CONSENT FORMStudent’s Name: ________________________________________________________Grade: __________ Age: __________CONSENT FOR COUNSELING SERVICESConfidentiality and Limits to ConfidentialityTrust and honesty are crucial to the development of all therapeutic relationships. Therefore, we place high value on the confidentiality of information you share within you sessions. You should, however, be aware that legal, ethical and licensure requirements specify certain conditions in which it may be necessary for you provider to discuss information about you care with other professionals,. If you have any questions about these limitations, please ask for provider before counseling begins. Such situations include:Danger that you may harm yourself or others, or are incapable for caring for yourself.Suspicion of abuse of children, elderly or disabled personsA Court Order to release you records.Your provider may sometime find it necessary to obtain professional consultation I n regards to the course of your care. Consultation regarding your case may be sought periodically with his/her supervisor and other colleagues only when needed. Your providers will inform you when he/she determines consultation is necessary. You identity may or may not be disclose when this occurs.I give permission for my child to receive counseling services from Crow Creek Tribal School orthrough Indian Health Services in Fort Thompson, SD. I understand that this service will begiven if and when my child’s behavior indicates the need. I understand that if I do not giveconsent for counseling services from the school or Indian Health Service, I must provide anoutside source for counseling if deemed necessary.In signing below, I acknowledge that I fully understand what I have read. I understand that Iwill have had an opportunity to ask questions as needed, and that I consent for mySon/daughter to participate in counseling with the CCTS School/Dorm and Ft. Thompson I.H.S.Behavioral Health Program if needed.________________________________________________________________________________________________Student SignatureDate________________________________________________________________________________________________Parent/Guardian SignatureDateCrow Creek Tribal SchoolsDAY Student Check out Form – 2018-2019(Dorm students must use the Dorm Check-Out Form when checking out during school.)It is very important the Parent/Legal Guardian have this form complete and notarized for the safety of our students. Students will not be allowed to check out of the dormitory or school unless they are released to a person whose name appears on this permission form. Any other special circumstances will have to be referred to a Principal, Dormitory Supervisor or Superintendent.________________________________________________________________________________________Student NameHome Reservation_________________________________________________________________________________________Parent/Legal GuardianPhone # you can be reached at immediately_____________________________________________________________________________________________________PO Box/AddressCityStateZipI hereby give the following adults permission to check out my son/daughter for week-ends or holidays.I understand that these adults must personally pick up the student and sign him/her out from the school (if during school hours) and from the dormitory.I understand that off reservation students may not check out to Ft. Thompson and surrounding communities for overnight unless with parents or legal guardian.(Handwriting must correspond to notarized signatures at bottom of the page)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I also give the school permission to seek out adequate housing and transportation for my son/daughter during emergencies.________________________________________________ ______________________________________________Signature of Parent/Legal GuardianVerified by Notary of the Public_______________________________________________________My Commissions Expires OnMedical Power of AttorneyFor Care of Minor ChildI affirm that I am the parent and/or legal guardian of the minor child named below:____________________________________________________________________________________Child’s FULL NameDate of BirthI hereby, give consent to the Crow Creek Tribal School Nursing staff to seek and obtain routine medical and dental care for this child at the Fort Thompson Indian Health Care Center (Dormitory or school staff may take students under special circumstances).In addition, I hereby give consent for the following adults to seek and obtain routine medical or dental care for this child at Fort Thompson Indian Health Center.SCHOOL STAFF??????School Year 2018 - 2019SCHOOL NURSEI understand that I or one of the above persons must accompany the child each time medical or dental care is sought; otherwise care will not be given until I (or the child’s other parent) have been contacted and give consent for care.I further understand that this consent applies only to routine medical and dental care that I must give additional consent for more complicated or difficult procedures. Written consent is not required for care during a serious emergency.THIS CONSENT EXPIRES AT THE END OF THE SCHOOL YEAR: MAY 24, 2019_________________________________________________________________ __________________________________________Signature Relationship Date_________________________________________________________________ __________________________________________Signature Relationship DateCROW CREEK SERVICE UNITFT. THOMPSON HIS HEALTH CENTERBUSINESS OFFICEPO BOX 200FT. THOMPSON, SD 57339(605) 245-1540AUTHORIZATION TO FURNISH INFORMATION AND ASSIGNMENT OF BENEFITSI authorize Ft. Thompson IHS Health Center to release medical information about me to my insurance carrier, workmen’s compensation carrier or SD Medicaid.I hereby assign insurance benefits that I may be eligible to receive, to the Ft. Thompson IHS Health Center as payment for medical services and supplies furnished to me by the IHS. I authorized direct payment of such benefits to the Indian Health Service, Ft. Thompson, SD 57339.____________________________________________Patient’s Name____________________________________________Patient/Parent/Guardian Signature____________________________________________DateTHIS CONSENT SHALL REMAIN VALID UNTIL REVOKED IN WRITINGNOTICE TO PATIENTSELIGIBILITY FOR DIRECT CARE:You must be eligible for DIRECT CARE. This care provided at the Ft. Thompson IHS Health Center. To be eligible for DIRECT CARE you must be an Indian/Native American from a Federally Recognized Tribe of the United States. You may reside anywhere within the United States. You are allowed up to 30 days to provide proof of being Indian/Native American and allowed 1 clinic visit. Proof shall be in the form of a letter, statement, or BIA Form 4432 from your Tribe, Which contains either enrollment number or degree of Indian Blood OR if NOT enrolled, proof of decadency/Lineage. It is the responsibility of the patient to obtain this proof. If proof is not shown within the time frame specified further services WILL NOT be allowed at the Ft. Thompson IHS Health Center.A medical doctor of the IHS may refer a person when the medical care required cannot be provided by the Ft. Thompson IHS Health Center. IHS WILL NOT AUTHORIZE PAYMENT for this care until the following eligibility requirements are met.ELIGIBILITY FOR PATIENT REFERRALS:You must be eligible for CONTRACT HEALTH CARE. This is care provided away from the IHS Facility. You must first meet the Direct Care requirements and you must reside within a delivery area called the “ON or NEAR Regulation” The “ON” refers to an Indian/Native American eligible for Direct Care and lives within the boundaries of the Crow Creek Sioux Reservation. The “NEAR” refers to the members of the Crow Creek Sioux Tribe who live near the Crow Creek reservation where the Ft. Thompson IHS Health Center is located. Members of the Crow Creek Sioux Tribe who reside within our CHS delivery is (i.e., Buffalo, Brule, Hand, Hughes, Hyde, Lyman, and Stanley Counties) will meet the “NEAR” regulation. If the patient is not enrolled with the Crow Creek Sioux Tribe and “DOES NOT” live on the Crow Creek Reservation the patient “IS NOT” eligible for Contract Health Services.If the patient does not meet BOTH eligibility requirements for DIRECT CARE and Contract Health Care, “IHS WILL NOT PAY” for care provided at a non-IHS health care facility.NON-INDIAN BENEFICARIES:Any Non-Indian woman pregnant with an eligible Indian/Native American child will be required to show proof that she is eligible for prenatal and postnatal services either through marriage to an eligible Indian/Native American male or by statement from the eligible Indian/Native American that she is carrying his child.I have read & received a copy of the above information.________________________________________________________________Signature DateACKNOWLEDGEMENT OF RECEIPT OF IHS NOTICE OF PRIVACY PRACTICESI HEREBY ACKNOWLEDGE RECEIPT OF THE INDIAN HEALTH SERVICE (IHS) NOTICE OF PRIVACY PRACTICES AT:FORT THOMPSON INDIAN HEALTH SERVICESPO BOX 200FORT THOMPSON, South Dakota 57339_________________________________________________________________Signature of PatientDate_________________________________________________________________Signature of Patient Representative Date(State relationship to patient or witness (if signature is by thumb print or mark)_________________________________________________________________Signature and Title of IHS EmployeeDateFOR PATIENTS UNABLE TO ACKNOWLEDGE RECEIPTI HEREBY CERTIFY THAT THE PATIENT WAS UNABLE TO ACKNOWLEDGE RECEIPT OF THE IHS NOTICE OF PRIVACY PRACTICES BECAUSE___________________________________________________________________________________________________________________________________Signature of IHS EmployeeDateDEPARTMENT OF HEALTH AND HUMAN SERVICESPUBLIC HEALTH SERVICEINDIAN HEALTH SERVICECONSENT OF PARENT OR LEGAL GUARDIAN OR OTHER PERSON 1WHO HAS PRIMARY RESPONSIBILITY FOR THE CARE OF THE CHILD(Before completing this form, please read information on reverse side.)Name ofStudent_____________________________________________Date of Birth ________________________I (We), ________________________________________________________________________________________Have read the Consent Form for the Indian Health to arrange for or to provide the following health services for this child:Health care including medical examinations, routing laboratory studies, x-ray procedures, and skin tests.Dental care including dental examinations, preventive use of fluorides and necessary emergency dental care.Mental health services including evaluation and treatment as necessary.Emergency health care for accidents or illness.Transportation of the child to and/or form another health facility for these services.??I hereby give consent for all the above services.?Exceptions or Special Instructions:________________________________________________________________________________________________________________________________________________________________________Signed__________________________________________Address________________________________________Relationship __________________________________Date _____________ Valid Until: ________________PLEASE RETURN THIS FORM TO THE SCHOOL(The third page of this form is for you to keep)1 Person is defined as one who in the absence of the parent of legal guardian provides a home for the child such as next of kin.CROW CREEK SERVICE UNITFT. THOMPSON HIS HEALTH CENTERBUSINESS OFFICEPO BOX 200FT. THOMPSON, SD 57339(605) 245-1540AUTHORIZATION TO FURNISH INFORMATION AND ASSIGNMENT OF BENEFITSI authorize Ft. Thompson IHS Health Center to release medical information about me to my insurance carrier, workmen’s compensation carrier or SD Medicaid.I hereby assign insurance benefits that I may be eligible to receive, to the Ft. Thompson IHS Health Center as payment for medical services and supplies furnished to me by the IHS. I authorized direct payment of such benefits to the Indian Health Service, Ft. Thompson, SD 57339.____________________________________________Patient’s Name____________________________________________Patient/Parent/Guardian Signature____________________________________________DateTHIS CONSENT SHALL REMAIN VALID UNTIL REVOKED IN WRITINGNOTICE TO PATIENTSELIGIBILITY FOR DIRECT CARE:You must be eligible for DIRECT CARE. This care provided at the Ft. Thompson IHS Health Center. To be eligible for DIRECT CARE you must be an Indian/Native American from a Federally Recognized Tribe of the United States. You may reside anywhere within the United States. You are allowed up to 30 days to provide proof of being Indian/Native American and allowed 1 clinic visit. Proof shall be in the form of a letter, statement, or BIA Form 4432 from your Tribe, Which contains either enrollment number or degree of Indian Blood OR if NOT enrolled, proof of decadency/Lineage. It is the responsibility of the patient to obtain this proof. If proof is not shown within the time frame specified further services WILL NOT be allowed at the Ft. Thompson IHS Health Center.A medical doctor of the IHS may refer a person when the medical care required cannot be provided by the Ft. Thompson IHS Health Center. IHS WILL NOT AUTHORIZE PAYMENT for this care until the following eligibility requirements are met.ELIGIBILITY FOR PATIENT REFERRALS:You must be eligible for CONTRACT HEALTH CARE. This is care provided away from the IHS Facility. You must first meet the Direct Care requirements and you must reside within a delivery area called the “ON or NEAR Regulation” The “ON” refers to an Indian/Native American eligible for Direct Care and lives within the boundaries of the Crow Creek Sioux Reservation. The “NEAR” refers to the members of the Crow Creek Sioux Tribe who live near the Crow Creek reservation where the Ft. Thompson IHS Health Center is located. Members of the Crow Creek Sioux Tribe who reside within our CHS delivery is (i.e., Buffalo, Brule, Hand, Hughes, Hyde, Lyman, and Stanley Counties) will meet the “NEAR” regulation. If the patient is not enrolled with the Crow Creek Sioux Tribe and “DOES NOT” live on the Crow Creek Reservation the patient “IS NOT” eligible for Contract Health Services.If the patient does not meet BOTH eligibility requirements for DIRECT CARE and Contract Health Care, “IHS WILL NOT PAY” for care provided at a non-IHS health care facility.NON-INDIAN BENEFICARIES:Any Non-Indian woman pregnant with an eligible Indian/Native American child will be required to show proof that she is eligible for prenatal and postnatal services either through marriage to an eligible Indian/Native American male or by statement from the eligible Indian/Native American that she is carrying his child.I have read & received a copy of the above information.________________________________________________________________Signature DateFt. Thompson IHS #________________PATIENT REGISTRATION INFORMATIONIn order for the Ft. Thompson Indian Health Center to continue providing efficient health services to you and your family, we must update your demographic information at every visit. This statistical information assists the Indian Health Center in providing a variety of services to you. If you have any questions please ask the Patient Registration Clerk or Patient Benefits coordinator for assistance.Patient Information:__________________________________________________________________________________________________________________________Last NameFirst NameMiddle NameDate of BirthSocial Security #_________________________________________________________________________________________________________________________Birth Place – City and StateMale or FemaleCurrent CommunityDate Moved There________________________________________________________________________________________________________________________Marital StatusALIAS Used (name)Religious Preference________________________________________________________________________________________________________________________Mailing Address – City, State, Zip CodeHome Phone #Work Phone #Cell or Message Phone #________________________________________________________________________________________________________________________Name of TribeBlood QuantumTribal Enrollment #** If you do not have your Tribal Enrollment Card/Paper with you, you will need to sign a 30 day notice****If you are not enrolled with any Tribe you must show proof that you a Tribal Descendent**Parent Information**Please write DEC – Behind Name if Deceased**Father’s Name________________________________________ Mother’s Name_____________________________________________Father’s Place of Birth_________________________________ Mother Place of Birth___________________________________Father’s Phone #______________________________________ Mothers Phone #_________________________________________Father’s Email Address________________________________ Mother’s Email Address_______________________ Mother’s Maiden Name_____________________________________________________________________________________________________________________________________________Employers Information:**If Minor Child-Please write Parent/Guardian Employer Info**Employer Name________________________________________Address_______________________________________________Employer Phone #______________________________________ _______________________________________________ Full Time/Part-time/Seasonal (circle one)Spouse Employer Name_________________________________Address_______________________________________________Spouse Employer Phone #__________________________ _______________________________________________ Full Time/Part-time/Seasonal (circle one)Emergency Contact Information: Next of Kin Information: Must be a relativeName_________________________________________________Name__________________________________________Address______________________________________________Address_______________________________________ _________________________________________________________________________________________________________ Phone #_________________ 2nd Phone #__________________ Phone #_________________ 2nd Phone #__________________Relationship to You ________________________Alternative Resource Information:**This information is necessary for billing and other resources such as MEDICAID or other Health Insurance****Insurance is billed directly to the carrier and not to you as the patient**Are you covered by MEDICAID?YesNoPLEASE SUBMIT CARD FOR FILEIf Yes, ID ______________________________________(Brown Card)Are you covered by MEDICARE?YesNoPLEASE SUBMIT CARD FOR FILEIf Yes, ID ______________________________________(White Card with Red & Blue Stripe)Are you covered by Private Health Insurance?YesNoPLEASE SUBMIT CARD FOR FILEIf Yes, ID ______________________________________Name of Insurance Company______________________________________________Effective Date_____________________Group #_________________________________________Name(s) of all insured_______________________________________________________________________________Veterans InformationAre you a Veteran?Yes No If Yes, what is you Serial Number_________________________Branch of Service ________________________Entry Date _________________________ Discharge Date_____________________Vietnam Connected?Yes No Service Connected Disability? Yes NoOther Patient Data:What Race are you? (Circle one)American Indian or Alaska Native/Asian/African American/White/OtherAre you Hispanic or Latino?Yes No UnknownWhat is your Primary Language?Do you need an Interpreter?Yes NoWhat is your Preferred Language?Do you have access to the Internet?Yes NoIf Yes, Where?Do you have an Email address?Yes NoIf Yes, What is your email address? _______________________________________________What is your preferred method of Contact? (Circle one)MailEmailPhone**You should have received a NOTICE OF PRIVACY PRACTICES, ASSIGNMENT OF BENEFITS FORM, and DIRECT CARE/CHS INFORMATION FORM for you to sign and date. This information will be electronically filed into our database as well as a hard copy placed in your chart. Please Note that all information you have given is CONFIDENTIAL and will be used only for your continued Health Care. Thank You for your cooperation**Interview Information:WAS YOUR INTERVIEW WITH PATIENT REGISTRATION IN A FRIENDLY MANNER?YESNODO YOU FEEL SECURE THAT YOUR RIGHTS AS A PATIENT ARE RESPECTED?YESNODO YOU FEEL YOUR RIGHTS TO PRIVACY, AS A PATIENT, ARE RESPECTED?YESNOPATIENT or PARENT/GUARDIAN SIGNATURRE _______________________________________ DATE________________** THIS CONCLUDES THE PATIENT REGISTRATION PROCESS. PLEASE REVIEW THIS DOCUMENT TO MAKE SURE THAT YOU HAVE FILLED IT OUT COMPLETELY**THANK YOUThis section to be completed by Patient Registration Staff:DATE RECEIVED:_________________________STAFF INITIALS:__________________________DATE ENTERED:__________________________STAFF INITIALS:__________________________IF YOU ARE INTERESTED IN ANY KIND OF SPORTS WHILE AT CROW CREEK TRIBAL SCHOOLS PLEASE GO TO THE FOLLOWING SDHSAA WEB SITE FOR PHYSICAL FORMS ................
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