Registration / Consent Screening Form

How would you like to fill the form?

Scan the FRONT of your insurance card

We'll read it and prefill the form for you

Take a photoUse your camera Upload a photoFrom your gallery

1/5 Patient Information

Patient Type

Child Adult

Child's First Name Child's Last Name Child's Date of Birth

School / Organization Gender Preferred language

Parent/Guardian First Name Parent/Guardian Last Name Phone E-mail PCP / Pediatrician Name PCP / Pediatrician Phone PCP / Pediatrician E-mail (optional) PCP / Pediatrician Address (optional)

Insurance Company Insurance ID / Policy # Secondary insurance company (optional) Secondary member / policy # (optional) Insurance Card — Front photo (optional) Tap to upload or take a photo

✓ Front photo attached from the scan

Insurance Card — Back photo (optional) Tap to upload or take a photo

✓ Back photo attached from the scan

Street Address City State / Province Zip / Postal Code

Signature

✓

Thank you!

Your registration has been received. Our team will contact you with the next steps.

Happy Feet 4 All — Preventative Care Program

HIPAA Disclosure

HIPAA Authorization for Use and Disclosure of Health Information

I authorize Happy Feet 4 All, LLC and participating healthcare providers involved in my care or my child’s care to use and disclose health information obtained through registration, screening, care coordination, and navigation services.

I authorize Happy Feet 4 All to share relevant health and screening information with appropriate medical professionals and healthcare organizations for the purpose of further evaluation, treatment coordination, referrals, and navigation of care. Provider options may be identified based on geographic location, availability, insurance participation, and the preference of the patient or parent/legal guardian.

The information disclosed may include registration information, screening findings, health history provided during registration, insurance information, and other information reasonably necessary to coordinate further evaluation or care.

I understand that:

Signing this authorization is voluntary.
I may choose among available healthcare providers and am not required to receive care from a provider recommended through Happy Feet 4 All.
I may revoke this authorization at any time by submitting a written request to Happy Feet 4 All, except to the extent that information has already been disclosed or action has already been taken in reliance on this authorization.
Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA.
This authorization will remain effective for one year from the date signed, unless revoked earlier in writing.

For an Adult: By signing, I authorize the use and disclosure of my health information as described above.

For a Minor: By signing, I certify that I am the parent or legal guardian authorized to provide this authorization on behalf of the child identified in this registration.