New York City Department of Education Oral Health Clinic Program

School Parental Consent Form

New York City Department of Education - Oral Health Clinic Program
STUDENT INFORMATION
Student Name*
Date of Birth
Month*
Day*
Year*
Student Address*
City*
State*
Zip Code*
School Name*
Grade*
Teacher’s Name
IMPORTANT MEDICAL QUESTION:
Does your child have any medical condition that may affect or complicate dental treatment? This may include heart, breathing or bleeding issues, seizures, allergies, communicable diseases, immune disorders, etc. If Yes, explain. IF NO, LEAVE BLANK
PARENT/GUARDIAN INFORMATION
Mother
Name*

First NameLast Name
Father
Name*

First NameLast Name
Legal Guardian, If Applicable
Name*

First NameLast Name
GrandparentAunt/UncleOther
Contact Information for Parent or Guardian
Home Tel*
Please enter a valid phone number.
Work Tel*
Please enter a valid phone number.
Cell*
Please enter a valid phone number.
Email*
example@example.com
Additional Emergency Contact
Name

First NameLast Name
Relationship to Student
Home Tel
Please enter a valid phone number.
Work Tel
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Email
example@example.com
INSURANCE INFORMATION
NoYes
Medicaid ID
NoYes
CHP #
AffinityHealthfirstHIPWellCareMVPFidelisHealth Plus AmericgroupMetroPlusUnited HealthcareEmpire BlueCross BlueShieldOther
NoYes
Health Plan
Member ID of Social Security Number
Health Insurance Phone
Name of Insured Adult
Birth Date of Insured Adult

MonthDayYear
Date
Services will be provided to your child regardless of whether or not your child has health insurance, at no cost.
PARENTAL CONSENT FOR SCHOOL-BASED HEALTH CLINIC SERVICES
I understand that my child will be receiving oral health services and my signature provides consent for my child to receive services provided by the OHCP for as long as my child is enrolled in school. I may withdraw my consent at any time by written notice to the OHCP. I understand that I will report any significant changes in my child’s health to the provider.

NOTE: By law, parental consent is not required for students who are 18 years or older or for students who are parents or legally emancipated. My signature indicates I have received a copy of the Notice of Privacy Practices.
Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law)*
Date*

MonthDayYear
Date
HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION
I have read and understand the release of health information on page 2 of this form. My signature indicates my consent to release health information as specified.
Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law)*
Date*

MonthDayYear
Date
CONSENT FOR SCHOOL-BASED ORAL HEALTH CLINIC SERVICES
I consent for my child to receive oral health care services provided by the State-licensed health professionals of the OHCP as part of the school oral health program approved by the New York State Department of Health for as long as my child is enrolled at school. I may withdraw my consent at any time by written notice to the OHCP. I understand that confidentiality between the student and the oral health clinic provider will be ensured for specific service areas in accordance with the law, and that students will be encouraged to involve their parents/guardians in counseling and oral care decisions. School-Based Oral Health Clinic Services may include, but are not limited to, preventative oral health services, restorative services, and emergency procedures. Preventative oral health services include, but are not limited to, comprehensive dental exams, dental hygiene treatments, x-rays, sealants and fluoride treatments. This may also include the application of Silver Diamine Fluoride on back teeth to halt the progression of cavities (Silver Diamine Fluoride may discolor any cavities resulting in a brown or black color). For services other than comprehensive dental exams and preventative oral health services, the OHCP shall notify the parent/guardian of the services and treatments to be provided including fillings, extractions, and the use of anesthetics or other medications. If the parent/guardian does not consent, these services shall not be performed.
HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION
I consent for my child to receive oral health care services provided by the State-licensed health professionals of the OHCP as part of the school oral health program approved by the New York State Department of Health for as long as my child is enrolled at school. I may withdraw my consent at any time by written notice to the OHCP. I understand that confidentiality between the student and the oral health clinic provider will be ensured for specific service areas in accordance with the law, and that students will be encouraged to involve their parents/guardians in counseling and oral care decisions. School-Based Oral Health Clinic Services may include, but are not limited to, preventative oral health services, restorative services, and emergency procedures. Preventative oral health services include, but are not limited to, comprehensive dental exams, dental hygiene treatments, x-rays, sealants and fluoride treatments. This may also include the application of Silver Diamine Fluoride on back teeth to halt the progression of cavities (Silver Diamine Fluoride may discolor any cavities resulting in a brown or black color). For services other than comprehensive dental exams and preventative oral health services, the OHCP shall notify the parent/guardian of the services and treatments to be provided including fillings, extractions, and the use of anesthetics or other medications. If the parent/guardian does not consent, these services shall not be performed.
Should be Empty:

School Parental Consent Form

STUDENT INFORMATION

Date of Birth

PARENT/GUARDIAN INFORMATION

Mother

Father

Legal Guardian, If Applicable

Additional Emergency Contact

INSURANCE INFORMATION

PARENTAL CONSENT FOR SCHOOL-BASED HEALTH CLINIC SERVICES

HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION

CONSENT FOR SCHOOL-BASED ORAL HEALTH CLINIC SERVICES

HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION