AltaMed School Based Dental & Behavioral Health Services Enrollment Form

I give my child permission to obtain BEHAVIORAL HEALTH/COUNSELING SERVICES while enrolled in a school serviced by AltaMed or until I revoke permission. All insurances will be billed at the time of the visit with no out-of-pocket fees or co-payments.
All insurances will be billed at the time of the visit with no out-of-pocket fees or co-payments.
I give my child permission to obtain ON-SITE/MOBILE DENTAL SERVICES while enrolled in a school serviced by AltaMed or until I revoke permission.

For patients enrolled in Medi-Cal Dental, services are 100% covered with no additional fees or charges.
For patients without Medi-Cal Dental, problem focused exam can be rendered.

RISKS: Although infrequent, some discomfort and soreness may occur with dental procedures.

I certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to the student/patient’s health. I will notify AltaMed of any changes to medical information.
I authorize the release of any medical, dental or behavioral health information necessary to process my claim. I also authorize payment of health benefits to AltaMed for services provided.
I understand that information regarding how AltaMed will use and disclose my information can be found in AltaMed’s Notice of Privacy Practices. A copy of the Notice of Privacy Practices can be viewed at www.AltaMed.org/ regulatory-notices. In addition to the uses and disclosures detailed in the Notice of Privacy Practices, I agree to permit AltaMed to send text messages to my child (only for scheduling purposes) or to me if a cell phone number(s) is listed below.
I hereby authorize AltaMed to exchange health and education records with my child’s school district for the purpose of providing care and treatment to my child, if applicable, and/or to exchange dental exam information. I recognize that health records if received by the school district, may not be protected by the HIPAA Privacy Rule, but will become education records protected by Family Education Rights & Privacy Act.

Student/Patient Information

Ethnicity
Race
Does the patient qualify for free/reduced lunch?
Does the student/patient have a dentist?

Student/Patient Insurance Information

Student/Patient Medical History

Student/Patient Medical History

Does the patient have any medical conditions?
Does the patient take any medications? (including inhalers)
Has the patient had any serious injuries?
Does the patient have a birth or heart defect or have history of a heart problem or surgery?
Has the patient had surgery in the past?
Is the patient pregnant or possibly pregnant?
Is premedication with antibiotics needed prior to dental procedures?
Does the patient smoke, vape, or chew tobacco?

Does the student/patient have or had any of these problems?

Anemia/blood disorders
Pneumonia
Asthma
Rheumatic fever, heart disease, murmur
Autism
Scoliosis
Bladder or kidney infections
Seizures
Cancer/leukemia
Thyroid disease
Chicken pox
Tuberculosis
Diabetes
Ulcer/digestive problem
Eating issues
Any mental health issues?
Endocrine/gland disease/autoimmune disease
Any birth or congenital defects?
Headaches/migraines
Any problems with teeth?
Hepatitis or liver problems
Any teeth causing pain?
Learning/developmental issues
Any bleeding when brushing or flossing?
Herpes
Had a dental cleaning within the last 6 months?
Overweight/obesity

Allergies

Any foods
Any medications (including over the counter or antibiotics; penicillin or amoxicillin)
Latex
Does the patient have an Epi-Pen at school?

Behavioral Health (Please complete ONLY if student/patient is in need of counseling services)

Would you like to enroll the patient in behavioral health services?
Has the patient ever had counseling services?
Has the patient been hospitalized for YES NO psychiatric emergency?

Has the patient have or had any of the following concerns?

Family changes
Truancy/school avoidance
Social/peer stresses
Grief/Recent Loss
Anxiety
Drugs or alcohol use
Anger issues
Self-esteem issues
Attention difficulties
Gender identity issues
Sadness and/or mood swings
Dental: (323) 558-7610
Behavioral Health:(855) 425-1777