IHCWV Ellenboro Campus Consent Forms

Student's Information

Parents/Legal Guardian (please list all working numbers)

EMERGENCY CONTACT(S) and Sharing of Protected Health Information (PHI) 

Please list anyone other than yourself, that has permission to bring the student to be seen AND indicate if we have permission to share the student's medical results with. You do NOT need to list medical providers or other medical institutions.

Health Insurance Information

Guarantor Information (who is responsible for the bill e.g. copay)

*Please fill out regardless of insurance status. Do NOT list insurance company's information here.

Student's Health Information

Student's Current/Past Medical History

Integrated Health Centers of West Virginia is a Federally Qualified Health Center (FQHC) and receives federal funding pursuant to Section 330 of the Public Health Service Act. We are required to collect information about age, gender, race, sexual orientation, income, and family size for statistical purposes only. No individual information is submitted.

Student's Race, Sexual Orientation, Gender ID, Ethnicity, Housing Status, and Language

Telehealth Informed Consent

Telehealth services involve the use of secure interactive videoconferencing equipment (Let’s Talk Interactive) that enable health care providers to deliver health care services to patients when located at different sites.

1.) I understand that the same standard of care applies to a telehealth visit as applies to an in-person visit.

2.) I understand that my child will not be physically in the same room as my provider. I will be notified of and my consent obtained for anyone other than the provider present in the room.

3.) I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
- If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that the provider may discontinue the visit and make other arrangements to complete the visit.

4.) I understand that I have the right to refuse my child’s participation or decide to stop participating in a telemedicine visit and that my refusal will be documented in my child’s medical record. I also understand that my refusal will not affect my child’s right to future care or treatment.

5.) I understand that the laws that protect privacy and the confidentiality of health care information apply to telehealth services.

6.) I understand that my child’s health care information may be shared with other individuals for scheduling and billing purposes.
- I understand that my insurance carrier will have access to my child’s medical records for quality review/audit.
- I understand that the guarantor will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my child’s telehealth visit.
- I understand that health plan payment policies for telehealth visits may be different from policies for in-person visits.

7.) I understand that this document will become part of my child’s medical record.

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternative to telehealth visits shared with me in a language I understand; and (3) am located in the state of West Virginia and will be in West Virginia during my telehealth visit(s).

Texting Consent

1.) IHCWV offers patients, parents or guardians the opportunity to communicate by text messaging. Text messaging is not to be used to convey medical information or to discuss medical conditions. Text message communication has a number of possible risks that patients, parents or guardians should consider before using text messaging. If the patient, parent or guardian is worried about any information being seen by other people, or if the question or problem is urgent, other form(s) of communication such as telephone or portal communication should be used. Some of the possible risks of using text messaging include, but are not limited to, the following:
- Text messages can be sent on to other people, stored on a computer, or printed out on paper for storage. b. Text message senders can easily misaddress their message. c. Text message information is easier to change than handwritten or signed documents. d. Text message information may be kept on computers/electronic devices even after the sender or the recipient believes they deleted his or her copy. e. Employers and on-line services have a right to archive (store) and look at text messages transmitted through their systems. Some, but not all, employers store text messages indefinitely. f. Text messages can occasionally be intercepted, changed, forwarded, or used without authorization or detection. g. Text messages can be used as evidence in court.

2.) The health care providers will use reasonable means to protect the security and confidentiality of text message information sent and received. However, because of the risks outlined above, the health care providers cannot guarantee the security and confidentiality (privacy) of text messaging communication, and will not be liable for improper use and/or disclosure of confidential information (including Protected Health Information that is the subject of the federal Health Insurance Portability and Accountability Act of 1996). Thus, the patient, parent or guardian must consent to the use of text for patient information.

I acknowledge that I have read and fully understand the information the health care provider/Practice has provided me regarding the Risks of using text messaging. I understand the Risks associated with the communication of text messages between the health care provider/Practice and me, and consent to the Conditions outlined. In addition, I agree to the above instructions, as well as any other instructions that the health care provider/Practice may impose regarding text message communications.

Parent/Legal Guardian Consent

By signing this consent, I authorize my child to be seen at the school health center. I understand that in case of an emergency, every effort will be made by the health center staff to notify me. The health center will attempt to call me when my child presents themselves to the health center. If they are unable to contact anyone, a note will be sent home with my child. By signing this consent, I am giving the health center, school nurse, and my child’s regular doctor (if applicable) permission to communicate and share medical information regarding my child’s medical condition and parental/guardian contact information on an as-needed basis with the understanding that this information will continue to be treated in a confidential manner. I authorize a physician, physician’s assistant, family nurse practitioner, behavioral health professional, or other health professional to provide necessary and/or advisable treatment to my child. I am aware that the Notice of Privacy Practice is posted at the health center. I authorize the health center to release information regarding treatment to third-party payers such as Medicaid or insurance benefits to be paid directly to the health center. I am financially responsible for non-covered services but understand that services will not be denied due to inability to pay. I understand telehealth services are available and I can request a telehealth appointment if desired. I understand that I may withdraw consent at any time by contacting the health center in writing or by phone.