Parents and students:

| am super excited to let you know about a fabulous opportunity coming to the high school this June. Do

you need a sports physical for the upcoming 2019-2020 school year? How aboutvaccinations? | am

happy to say that Cox Care Mobile will be at the high school to provide these services on June 4th, June

20, and June 25".

Let’s talk sports physicals. Is your student enrolled in a weights class next year? Is your student involved

in a sport? If so, a sports physical will be required. Did you know thatif you receive free and reduced

lunches, on Medicaid, or have no insurance,that this is a free service? Don't meet the previouscriteria,

no sweat,its only $10. That's right only $10! All you needto doisfill out the paper work and returnit to

the front desk by May 17". Our school nursewill call you and set up an appointmenttime. Instructions

on how to make the paymentare includedin this packet.

Let's talk vaccinations. Is your student missing some vaccinations? We’ve got you covered. Did you

knowthatif you have Medicaid or no insurance,this is a free service? If not, don’t worry.Just call the

numberon the back of your insurance card. If your insurance companycovers vaccines, just make a

copy of the front and backofthe card,fill out the enclosed forms, and return it to the high school by

May 17". Our school nursewill then call you and set up an appointment.

Enclosed you will find the following forms:

e C.A.R.E mobile registration- this MUSTbefilled out for both sports physicals and vaccinations.

The back is for vaccinations only. Good news: this is good for a year. So if you are interested in

next year’s flu shotclinic or vaccination clinic, you’re covered.

e =C.A.R.E Mobile authorization form- MUSTbefilled out and signed by parent.

e MSHSAASport physical history form- MUST be completelyfilled out and signed by parent

e Informational flyer with paymentinstructions for physicals.

Please return:

e All forms (3) for sports physicals and (2) for vaccinations only.

e Copy of insurance card- front and back

Rememberthatthis is good for a whole year. So if you wish your child to participate in our fall or spring

vaccination clinic, you can fill out and return formsat this time. The deadline to turn in paper workfor

the June clinics is Friday May 17'". If you have any questions, pleasecall 345-5628.

Thank you,

Lisa Crawford RN, BSN, CEN

High School Nurse

Ill CoxHealth Name: 00000000000"An Regional Services Age: DOB:_//

ENT C.A.R.E. MOBILE REGISTRATION SSN or ID:(or Patient Sticker Here)

Child's Legal Name: SSN#: Birth Date : / /

Sex: [Male [Female Address: City: State: Zip:

School: Primary Language: English [Spanish (Other:

FINANCIAL OBLIGATION* =.:

PRIMARY INS: POLICY HOLDER NAME:

Policy Holder's Employer: Policy Holder SSN#:

Group #: Policy/ID #: Policy Holder DOB: __/_/

Patients Relationship to Policy Holder: [Child DI Other (explain)

SECONDARY INS: POLICY HOLDER NAME:

Policy Holder's Employer: Policy Holder SSN#:

Group#: Policy/ID #: Policy HolderDOB: __/ /

Patients Relationship to Policy Holder: [Child DI Other (explain)

OU NO INSURANCE(SELF PAY) STUDENT QUALIFIES FOR FREE OR REDUCED LUNCH? DYes DNo

* The mission of the C.A.R.E. Mobile program is to provide access to health care for children in the Ozarks who have no insurance, do not have a

primary care physician or whose parents cannotafford to pay for necessary services. However, nochild will be turned away.

PARENT OR GUARDIAN and EMERGENCY CONTACT INFORMATION

Emergency Contact: Phone: Relationship:

RELATIONSHIP: OFather Mother [Guardian

Name:(First, MI, Last) SSN#: Date of Birth://

Address: City/State/Zip: HomePhone:

Employer: Work Phone: Mobile Phone:

Preferred method of contact? [Email DJHome Phone DlLetter Cl Mobile Phone Work Phone

RELATIONSHIP: OFather [Mother O Guardian

Name:(First, MI, Last) SSN#: | Date ofBirth; __/7

Address: City/State/Zip: Home Phone:

Employer: Work Phone:: Mobile Phone:

Preferred method of contact? Email [Home Phone (Ul Letter D Mobile Phone D Work Phone

FAMILY HISTORY

Ethnicity: CJ Hispanic or Latino DI American Indian or Alaska Native ClAsian (Black or African American [White [] Native Hawaïïan or Other Pacific Islander

Patient's biological family hasa history of:

U Stroke O Heart disease or heart attack O Diabetes/sugar disease QO High blood pressure

XO High cholesterol O Diabetes/sugar disease DAsthma O Hearing loss at young ageÜ Vision loss at young age DJAlzheimer's disease/dementia 1 Developmentaldelay/retardation 1 Miscarriage/stillbirthO Breast cancer CO) Ovarian cancer O Endometrial (uterine) cancer [ Colon cancerO Birth Defects O Genetic conditions:

O OtherCancer(s):

O Genetic Conditions:

O Mental Health:

O OtherHealth Concerns:

Identify family members with each condition checked:

Relationsh Condition e of Onset Current and Cause of Death

Grandmotheron Father's Side igh Blood Pressure 61 87, Stroke

CPS-3028.12 01-18 Rev.01-18 CONTINUED ON BACK Page 1 of 2

CoxHealth Name: |

Regional Services Age: DOB:_//

“CONSNT* C.A.R.E. MOBILE REGISTRATION SSNor D:(or Patient Sticker Here)

CONTINUED FROM FRONT

SCREENING CHECKLIST FOR CONTRAINDICATIONS TO VACCINES

For parents/guardians: Thefollowing questions will help us determine which vaccines your child may be given. If you answer“yes” to

any question, it does not necessarily mean your child should not be vaccinated. It just means additional questions must be asked. If a

questionis not clear, please ask your healthcare providerto explain it.

1. Is the child sick today? O Yes [No O Don't Know

2. Doesthe child have allergies to medications, food, a vaccine component,orlatex? O Yes ONo O Don't Know

3. Hasthe child had a serious reaction to a vaccine in the past? O Yes ONo O Don't Know

4. Hasthe child had a health problem with lung, heart, kidney or metabolic disease

(e.g., diabetes), asthma, or a blood disorder? OU Yes ONo O Don't Know

Is he/she on long-term aspirin therapy? [Yes O No O Don't Know

5. Has the child, a sibling, or a parent had a seizure; has the child had brain or other

nervous system problems? O Yes O No O Don't Know

6. Doesthe child or a family member have cancer, leukemia, HIV/AIDS,or any other

immune system problems? OYes [No O Don't Know

7. Inthe past 3 months, has the child taken medications that affect the immune system

such as prednisone,other steroids, or anticancer drugs; drugs for the treatment of

rheumatoid arthritis, Crohn’s disease, or psoriasis; or had radiation treatments? O Yes ONo O Don't Know

8. In the past year, has the child received a transfusion of blood or blood products,

or been given immune (gamma) globulin or an antiviral drug? O Yes UNo O Don't Know

9. Is the child/teen pregnantoris there a chance she could becomepregnant during

the next month? O Yes UNo O Don't Know

10.Hasthe child received vaccinations in the past 4 weeks? O Yes ONo O Don't Know

Please send yourchild's immunization record card with them on the day oftheir visit to the C.A.R.E Mobile.

It is important to have a personalrecord of your child's vaccinations. If you don’t have one,ask the child's healthcare provider to

give you one with all your child's vaccinations on it. Keepit in a safe place and bring it with you every time you seek medical care

for yourchild. Your child will need this document to enter daycare or school, for employment, or for internationaltravel.

VACCINE RECORD (FOR C.A.R.E. MOBILE USE ONLY)

Vaccinesfor Children (VFC) Program Eligibility Status: [U Medicaid O Nohealth insurance O American Indian/Alaska Native

O Underinsured (FQHC/RHC)Diphtheria, Tetanus O NOT VFCEligible

Vaccine Route M/D/Y Given Injection Manufacturer Lot Number Exp. Date NDC Number VIS Rev. Date VIS

Site Date Given

Ex: Hib IM 01/01/18 LeftArm Sanofi Pasteur AA123AA 01/01/18 49281-547-58 01/01/18 01/01/18

Comments:

Vaccinator Signature VaccinatorTitle Date

CPS-3028.12 01-18 Rev.01-18 Page 2 0f2

NN*AUTHOR*

Child’s Legal Name:

Sex: UU Male [ll Female Address:

CoxHealth Name:Regional Services Age: DOB:_//

C.A.R.E. MOBILE AUTHORIZATION SSNor D:(or Patient Sticker Here)

SSN#: Birth Date:/7

City: State: Zip:

School:

Primary Language: [IEnglish DJSpanishn Other:

This Authorization, Financial Obligation ‚Consent and Permission to Share form applies to the CoxHealth C.A.R.E. Mobile (hereinafterreferred to as "CoxHealth”).

Authorization to Release Information. The Notice of Privacy Practices setsforth rights regarding my child’s personal health information and the mannerinwhichit may be usedor disclosed. This includes the sharing and/or receivingof prescription information with a prescription databaseutilized in electronicallyprescribing medications for my child's treatment, including the review andaccess to prescriptions prescribed to my child outside of the CoxHealthsystem. | understand that | have the following rights, among others, regardingmy child's information: to receive the Notice of Privacy Practices prior tosigning this form; to object to the use of my child's personal health informationin anyfacility directory; and to revokethis form in writing, except to the extentthat CoxHealth has already taken action in reliance on this form. | authorizethe review, copying, release and disclosure of any andall information in mychild’s medical or accounting record(s), including information regarding thediagnosis or treatment of HIV, AIDS, mentalillness or substance abuse, toany person, corporation or agency responsible for determining the necessity,appropriateness, payment, continuity of care or other matters related to thetreatmentor services rendered to me by CoxHealth.

Assignmentof Benefits. | assign to CoxHealth the benefits otherwisepayable to me for any treatment from my insurancecarrier or company,managedcareplan, health maintenance organization, self-insured health plan,Medicaid or Medicare andits intermediaries and carriers.

Financial Obligation. | understand that | am financially responsible forpaymentofall amounts due for services provided by CoxHealth regardlessof whether | have insurance coverageor whetherother parties may also beresponsible for paying for my child's care. | will not be responsible to payfor such services renderedif myfinancial obligation is waived by contractualagreementorprohibited by applicable state or federal laws or regulations.| understand that, as a courtesy to me, CoxHealth will submit claims forthird-party coverage to my disclosed insurance carriers and that CoxHealthis authorized to complete any forms which are neededin orderto obtainpayment from said third-party payers. For all past due accounts,| agree topay interest at the legal rate if the amount for which | am responsible is notpaid within thirty (30) days of receipt of the bill. As part of the collectionsprocess, | authorize CoxHealth and anyofits agents attempting to collect anunpaid account balance to contact me at any telephone numberor address|have provided to CoxHealth using any manner, including the use of an auto-dialing device, at any time until my debts are paid in full. | understand thatthe cost of collections on past due accounts,including reasonable attorney'sfees and courtcosts, will be included as part of myfinancial obligation. Thisagreement shall be governed by Missouri law. | hereby agree venueshallbe appropriate in Greene County, Missouri. | also understand, pursuant tothe Missouri hospitallien statutes, thatif my injuries were caused by thenegligence or wrongful act of another, CoxHealth may have lien on any andall claims or rights of action | may have against the person causing my injuriesand CoxHealth may havethe right to enforce the lien for paymentof servicesrendered rather than seek paymentfrom anythird-party payer.

Medicaid Beneficiaries. | authorize CoxHealth to obtain information fromMissouri HealthNet or other government agencies regarding my entitlementtobenefits and my health insurance claim numbers.

Consent for Treatment. | agree, request and authorize the schoollisted aboveto facilitate treatment and health care for my child thatis to be provided by the CoxHealthC.A.R.E. Mobile program,including but notlimited to: primary care services, immunizations, vision services, sports pre-participation physicals, and the treatmentofcommonillnesses. | have been given a copy and haveread,or had explained to me,the information in the “Vaccine Information Statement(s),” where applicable, for anythe vaccine(s) my child will receive from CoxHealth. | have had a chance to ask questions and had them answeredto mysatisfaction. | understand the benefits and risksof the vaccine(s) requested andaskthat the vaccine(s) currently due for which | have signed below be given to my child. | am authorized pursuant to Section 431.058RSMoto makethis request. | realize that among those whoattend to patients at CoxHealth are medical, nursing and other healthcare personnelin training who may bepresent and participating in my child's care as part of their education. | also understand that CoxHealth utilizes the services of Non-Physician Practitioners, that my childmay be evaluated and treated by one of these Non-Physician Practitioners and that | have the right to see that provider's collaborating physician. | authorize the taking ofphotographs, videos or other imagesof parts of my child's body for use in medical evaluation, education and security purposes. | am aware thatthe practice of medicineisnot an exact science and | understand that no promise, guarantee or warranty has been made regarding the results of the examination or treatment my child receives.

Permission to Share Information. | understand that protected health information (PHI) may include recordsrelating to psychiatric or psychological care; communicablediseases; HIV/AIDS diagnosis or treatment; alcohol or drug abuse treatment; sexually transmitted diseases; and other sensitive information.

| understandthat treatment, payment, enrollmentoreligibility for benefits may not be conditioned on whether| sign this authorization.

| understand that any disclosure of information carries withit the potential for unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.

____| authorize the release of financial and PHI from the entire CoxHealth system andits Affiliated Covered Entities.

___ 1 DO NOTauthorize the release of financial and PHI from the following entity(s):

« In the case of an emergency situation CoxHealth may determine that a limited disclosure may be in my child's best interests and | realize CoxHealth may sharelimitedPHI orotherinformation with those who may beinvolved in my child’s care.

« | relize this form does NOTauthorize the person(s) below to make health care decisions for my child or to view or receive copies of my child's medical records.

Type of Information

Relationship to

patient:

Insurance /

BillingScheduling /

Name: AppointmentPhone Number: All Medical

This covers the following time frames. If NOT marked, all past present, and future encountersare the default.

____All past, present, and future encounters/visits -OR- Other:

Time Limit and Right to Revoke. Except to the extent that action has already been takenin reliance on this authorization, | have the right to revoke this authorization atany time. Unless otherwise revoked, this authorization shall terminate one (1) year from the date signed.

Signature of Parent or Legal Guardian

(If unable to sign, Representative name ansd Relationship)CPS-3028.11 01-18 Rev.01-18

Date Signature of Witness Date

Page 1

PRE-PARTICIPATION PHYSICAL EVALUATION

HISTORY FORM(Note: This form isto be filled out by the patient and parentprior to seeingthe physician. The physician should keep a copyofthis form in the chart fortheir records).

Date of Exam:

Name: DateofBirth:Sex: | Age: | Grade: | School: Sport(s):

Medicines andAllergies: Pleaselist all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking:

Doyou have anyallergies: Yes No O If yes, please identify specific allergy below:

O Medicines: O Pollens: O Food: OQ Stinging Insects:

Explain “Yes” answers below. Circle questions you do not know the answerto.

GENERAL QUESTIONS Yes No MEDICAL QUESTIONS Yes No1. Has a doctor ever deniedorrestricted yourparticipation in sportsfor 26. Do you cough, wheeze,or havedifficulty breathing duringorafter

any reason? ‘ exercise?

2. Do you have any ongoing medicalconditions? If so, please identify 27. Have you ever used an inhaler or taken asthma medicine?below: DJAsthma Anemia ClDiabetes [infections 28. Is there anyonein your family who has asthma?Other: 29. Were you born withoutor are you missing a kidney, an eye, a testicle

3. Have you ever spentthe nightin the hospital? (males) or spleen,or any other organ?

4. Have you ever had surgery? 30. Do you have groin pain or a painful bulge or hemiain the groin area?

HEART HEALTH QUESTIONS ABOUT YOU Yes No 31. Have you hadinfectious mononucleosis (mono) within the last month?5. Have you ever passed out or nearly passed out DURING or AFTER 32. Do you have anyrashes, pressure sores, or other skin problems?

exercise? 33, Have you had a herpes or MRSAskininfection?6. Have you ever had discomfort, pain, tightness,or pressure in your 34. Have you ever had a headinjury or concussion?

chest during exercise? 35. Have you everhada hit or blow to the head that caused confusion,7. Does your heart everrace orskip beats (irregular beats) during prolonged headaches, or memory problems?

exercise? 36. Do you havea history of seizure disorder?8. Has a doctor evertold you that you have any heart problems? If so, 37. Do you have headacheswith exercise?

checkall that apply: 38. Have you ever had numbness,tingling, or weaknessin your arms orUJHigh blood pressure O A heart murmur legs after being hit or falling?

CHigh cholesterol O heart infection 39, Have you ever been unable to move your armsorlegs after being hitCiKawasakidisease O Other: or falling?

9. Has a doctor ever ordered a test for your heart? (For example, 40. Have you ever becomeill while exercising in the heat?ECG/EKG,echocardiogram) 41. Do you get frequent muscle cramps when exercising?

10. Do youget lightheadedorfeel more short ofbreath than expected 42. Do you or someonein your family have sickle cell trait or disease?during exercise? 43, Have you had any problems with your eyesor vision?

11. Have youever had an unexplained seizure? 44. Have you had anyeye injuries?12. Do you get moretired or short of breath more quickly than yourfriends 45. Do you wearglassesorcontact lenses?

during exercise? 46. Do you wearprotective eyewear, such as goggles ora face shield?HEART HEALTH QUESTIONS ABOUT YOUR FAMILY Yes No 47._Do you worry about your weight?13. Has any family memberorrelative died of heart problems or had an 48. Are youtrying to or has anyone recommendedthatyou gain or lose

unexpected or unexplained sudden death before age 50(including weight?drowning, unexplained car accident, or suddeninfant death 49. Are you on a specialdiet or do you avoid certain typesoffoods?

syndrome)? 50. Have you everhad an eating disorder?14. Does anyonein your family have hypertrophic cardiomyopathy, Marfan 51. Do you have any concernsthat you would like to discusswith the

syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT doctor?syndrome, short QT syndrome, Brugada syndrome,or FEMALES ONLY Yes Nocatecholaminergic polymorphic ventricular tachycardia? 52. Have you ever had a menstrual period?

15. Does anyonein your family have a heart problem, pacemaker, or 53. How old were you when you had yourfirst menstrual period?implanted defibrillator? 54. How many periods have you hadin the last 12 months?

16. Has anyonein yourfamily had unexplained fainting, unexplainedseizures, or near drowning? Explain “Yes” answers here:

BONEAND JOINT QUESTIONS Yes No17. Have you ever had aninjury to a bone, muscle, ligament, or tendon

that caused you to miss a practice or a game?

18. Have you ever had any brokenorfractured bonesordislocated joints?

19. Have you ever had aninjury that required x-rays, MRI, CT scan,injections, therapy, a brace,a cast, or crutches?

20. Haveyou everhad a stress fracture?

21. Have you ever beentold that you have or have you had an x-rayforneckinstability or atlantoaxialinstability? (Down syndrome ordwarfism)

22. Do you regularly use a brace,orthotics, or otherassistive device?

23. Do you have a bone, muscle,or jointinjury that bothers you?

24. Do anyof yourjoints becomepainful, swollen, feel warm,or look red?

25. Do you have anyhistory ofjuvenile arthritis or connective tissue

disease?

| herebystate that, to the best of my knowledge, my answers to the above questions are complete and correct.

Signature of Athlete: Signature of Parent(s) or Guardian: Date:

If we cannot be reachedandin the eventof an emergency, wealso give our consentfor the schoolto obtain through a physician orhospitalof its choice, such medicalcare as is reasonably necessary for the welfare of the student,if he/sheis injured in the course ofschoolathletic activities. We authorize the release of necessary medical information to the physician, athletic trainer, and/or school

personnel related to such treatment/care. We understandthat the school maynotprovide transportation to all events, and permit / do notpermit (CIRCLE ONE) mychild to drive his/her vehicle in such a case.

To enable the MSHSAA to determine whetherthe herein named studentis eligible to participate in interscholastic athletics in the MSHSAA

member school, | consentto the release of any andall portions of schoolrecordfiles to MSHSAA, beginning with seventh grade, of theherein named student, specifically including, withoutlimiting the generality of the foregoing, birth and age records, name and residence

address ofparent(s) or guardian(s), residence addressof the student, academic work completed, grades received,and attendancedata.

Weconfirm that this application for the above student to represent his/her schoolin interscholastic athletics is made with the

understandingthat we have studied and understand theeligibility standards that our son/daughter must meetto representhis/her schoolandthat he/she has not violated any of them. We also understandthatif our son/daughter does not meetthecitizenship standards set by

the schoolorif he/she is ejected from an interscholastic contest because of an unsportsmanlike act, it could result in him/her not being

allowedto participate in the next contest or suspension from the team either temporarily or permanently.

I consent to the MSHSAA’s use ofthe herein named student’s name,likeness,and athletic-related information in reports of contests,promotionalliterature of the Association and other materials and releasesrelated to interscholastic athletics.

Wefurther state that we have completedthatpart of this certificate which requiresustolist all previous injuries or additional conditionsthat are known to us which mayaffect this athlete's performance ortreatment andwecertify thatit is correct and complete.

The MSHSAA By-Lawsprovidethat a studentshall not be permitted to practice or compete for a schooluntil it has verification that he/shehasbasic health/accident insurance coverage, which includes athletics. Our son/daughter is covered by basic health/accident insurancefor the current schoolyearas indicated below:

Nameof Insurance Company: Policy Number:

Signature of Parent(s) or Guardian: Date:

PARENT AND STUDENT SIGNATURE(Concussion Materials)

| accept responsibility for reporting all injuries andillnesses to my school and medicalstaff (athletic trainer/team physician) including any signs andsymptoms of a CONCUSSION. | have received and read the MSHSAA materials on Concussions, which includes information on the definition of aconcussion, symptomsof a concussion, whatto doif | have a concussion and howto preventa concussion. | will inform my school and athletictrainer/team physician immediatelyif ! experience any of these symptomsorif | witness a teammate with these symptoms.

Signature of Athlete: Date:

Signature of Parent(s) or Guardian: Date:

EMERGENCY CONTACTINFORMATION

Parent(s) or Guardian Address Phone Number

Nameof Contact Relationship to Athlete Phone Number

Nameof Contact Relationship to Athlete Phone Number

Buffalo High School

June 4th, June 20th, & June 25th

Children’s %Miracle NetworkHospitals

NEED A SPORTS PHYSICAL? NO SWEAT.

Sports Physicals will be provided by the Cox CARE Mobile at Buffalo

High Schoolon June 4th, June 20th & June 25th for your convenience.

If you have Medicaid coverage, no insurance, or qualify for free or reduced

lunches, THE PHYSICAL IS FREE OF CHARGE. Otherwise,the physicalwill be $10.

There are 3 ways to make your payment:

Option 1:

1. Call (417) 269-4353 and indicate you are pre-paying for a sports physical to be

performed on the CARE Mobile

2. Provide the operator with your Visa, MasterCard or Discover information

Option 2:

1.Mail your check or moneyorder payable to CoxHealth CARE Mobile

2.Please include student name,date of birth, and school on your check

3.Mail to: CoxHealth

3355 S. National Ave.

Suite 400

Springfield, MO 65807

Option 3:

Go online to www.directconnectmenow.com

Click “yes” you are located in the state of Missouri

Enter CMsport as your plan code

Select Pre-Pay CAREMobile

Fill out the fields with your child’s information

You will be prompted to pay $10 with your credit or debit card information

Soap

woES

Print or screen shot your receipt