Student Information and Consent

Immunizations (Shots)

Your school nurse and the School Based Clinic team will review your child’s record to determine which shots are needed. School Required Immunizations:

- DTap/T'd

- Tdap

- Polio

- Heapatitis B

- MMRV(Measles, Mumps, Rubella, Varicella)

Pediatric/Adolescent Recommended Immunizatoins:

- Influenza (Flu)

- Human Papillomavirus (HPV)

- Meningococcal B

Please visit http://www.immunize.org/vis/ to find the Vaccine Information Statement for each vaccine, which will explain risks and benefits of all vaccines.

 

 NOTICE OF HEALTH INFORMATION PRACTICES (READ ONLY)

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other health care provider, a record of your visit is made.  Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.  This information, often referred to as your health or medical record, serves as a:

·         Basis for planning your care and treatment

·         Means of communication among the many health professionals who contribute to your care

·         Legal document describing the care your received

·         Means by which you or a third-party payer can verify that services billed were provided

·         A tool in educating health professionals

·         A source of data for medical research

·         A source of information for public health officials charged with improving the health of the nation

·         A source of data for facility planning and marketing

·         A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve

Understanding what is in your record and how your health information is used helps you to:

·         Ensure its accuracy

·         better understand who, what, when, where, and why others may access your health information

·         make more informed decisions when authorizing disclosure to others

Your Health Rights Information

Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you.  You have the right to:

·         request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522

·         obtain a paper copy of this notice upon request

·         inspect and obtain a copy of your health record as provided for in 45 CFR 164.524

·         amend your health record as provided for in 45 CFR 164.528

·         obtain an accounting of disclosures of your health information as provided for in 45 CFR 164.528

·         request communications of your health information by alternative means or at alternative locations

·         revoke your authorization to use or disclose health information except to the extent that actions have already been taken

Our Responsibilities

This organization is required to:

·         maintain the privacy of your health information

·         provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you

·         abide by the terms of this notice

·         notify you if we are unable to agree to requested restriction

·         accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

 We reserve the right to change our practices and to make new provisions effective for all protected health information we maintain.  Should our information practices change, we will mail a revised notice to the address you’ve supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice.

For More Information or To Report a Problem

If you have questions or would like additional information, you may contact our office.

If you believe your privacy rights have been violated, you can file a complaint with Beverly Clark, HIPAA officer or with the Secretary of Health and Human Services.  There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment, and Health Operations

We will use your health information for treatment.

For example, Information obtained by a nurse, provider, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you.  Your provider will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations.  In that way, the provider will know how you are responding to your treatment.  We will also provide your provider or a subsequent health care provider with copies of various reports that should assist in treating you once you are discharged.

We will use your health information for payment

For example:  A bill may be sent to you or a third-party payer.  The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

We will use your health information for regular health operations

For example:  Members of the medical staff, the risk quality manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it.  The information will then be used in an effort to continually improve the quality and effectiveness of the health care and services we provide.

We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care.

We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Special Situations:

Business Associates:  There are some services provided in our organization through contacts or agreements with business associates.  Examples include physician services in various departments, radiology, certain laboratory tests etc. When these services are utilized, we may disclose your health information to our business associates so they can perform a job we’ve asked them to do and bill you or your third-party payer for services rendered.  Please know and understand that all our business associates are obligated to comply with the same HIPAA privacy and security rules in which we are obligated.  We require business associates to appropriately safeguard your information.

Notification:  We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location and general condition.

 Communication with family:  Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Research:  We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Coroners and Medical Examiners:  We may disclose health information to coroners and medical examiners to assist in the fulfillment of their work responsibilities and investigations consistent with applicable law.

Public Health:  As required by law, we may disclose your health information to the public or legal authorities charged with preventing or controlling disease, injury or disability.

Correctional Facilities:  Should you be an inmate of a correctional facility, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Lawsuits and disputes:  If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order.  We may also disclose medical information about you in response to a subpoena, discovery request, or lawful process by someone else involved in the dispute, but only if efforts have been made to inform you of the request or to obtain an order protecting the requested information.

Law Enforcement:  For example, we may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.  In some circumstances we may disclose information about you to law enforcement officials if we believe in good faith, you have been a victim of a crime.  

Military, National Security, and other Specialized Government Functions: If you are in the military or involved in national security or intelligence, we may disclose your Protected Health Information to authorized officials

Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

The purpose of this Consent Form is to allow parents/guardians to give informed consent for your child to participate in and receive treatment from a Noxubee Medical Complex (NMC) healthcare provider through its School Based Clinic with or without the presence of a parent/guardian.

Consent for Health Services/Treatment

By signing below, the Parent/Guardian consents for your child to receive the necessary and/or advisable School-Based Health Services listed below in this section of the Consent Form (“Services”") from a NMC healthcare provider through the School Based Clinic. The Parent/Guardian understands that he/she can ask and have any questions answered about the risks, benefits, and alternatives of the services by contacting Noxubee Medical Complex at (662) 726-4264 and that Noxubee Medical Complex recommends the Parent/Guardian do so prior to signing this Consent Form if he/she has any questions about the services. The Parent/Guardian further understands that examination and treatment may be in-person or by telehealth. The Parent/Guardian acknowledges and understands that by signing this Consent Form, he or she is consenting to the services provided. Services include Physical Exams (Well child, EPSDT, Sports Physicals etc.), Care and Treatment for injury/illness, Routine lab tests, Prescription medications, Care for common pediatric/adolescent health concerns (weight, acne, menstrual problems), Care of certain Chronic conditions (such as asthma, diabetes, hypertension), Immunizations, Health education and prevention programs. 

Fiscal Accountability

If your child has Private Insurance, Medicaid, MSCAN, or MSCHIP we will file for the services provided. However, you will NOT be charged for any balances not paid by the insurance company provided at the school-based clinic. NMC will bill your child’s insurance carrier(s) for charges and fees covered by your child’s insurance plan. Parent/Guardian agrees to provide complete, accurate and timely information relating to any available health insurance for NMC toseekpayment in a timely manner.

Authorization to Release Health Information

I authorize that my child’s medical information, including diagnosis, treatment records, vaccinations, and/or lab results can be provided to NMC Health Personnel for treatment, referral, and/or care coordination. I authorize NCSD staff to provide a copy of medical information or other relevant personal information within my child’s school records to facilitate the assessment of my child’s health needs, coordinate my child’s care, or to provide treatment or referrals. I have received a copy of the Notice of Privacy Practices.