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Lions Health and Wellness School Based Health Center 501-984-4210

Jessieville School District wants to support the health, well-being and academic success of our students, enabling them to thrive in the classroom and beyond. Our mission is to strengthen student's integrity, engagement, and success in a safe and orderly environment.

What is a School Based Health Center and what services does the health center provide? A school based health center is an on campus healthcare clinic. Lions Health and Wellness is located on the Jessieville School campus. The Jessieville School District has partnered with CHI St Vincent Hot Springs. The clinic can provide the following types of care: Primary Care for illness and injury Comprehensive Annual Exams Laboratory Tests Prescription Medications Health Promotion and Prevention Programs Will my child see the medical practitioner without my permission? No! Every attempt will be made to contact the parent prior to your child seeing the CHI St. Vincent medical staff at Lions Health and Wellness.

What about prescriptions? No child will leave the clinic with medication or a written prescription. All student prescriptions will be called into the parent's pharmacy of choice or held at the clinic for pick up by a parent.

Patient Name

Home Address

Preferred Phone

Format: (000) 000-0000.

Alternate Phone

Format: (000) 000-0000.

Birthdate

Date

Parent/Guardian Name

Preferred Pharmacy

Phone

Format: (000) 000-0000.

Please list whom we may notify in the event of an emergency:

Contact

Relationship

Telephone

Format: (000) 000-0000.

Contact

Relationship

Telephone

Format: (000) 000-0000.

Primary Medical Insurance

Group Number

Insurance ID Number

Patient's Relationship to insured: Self ChildOther:

Other

Secondary Medical Insurance

Group Number

Insurance ID Number

Primary Care Physician

*Please provide a copy of your insurance card as well as a photo id.

Complete this section if patient is a minor

Responsible Party

Relation to Patient

Birth Date

Date

SSN

Age

Marital Status: Single Married Widowed Divorced

Spouse's Name

Mailing Address if different from patient

Employer

Work Phone

Format: (000) 000-0000.

All operations of Lions Health and Wellness and their providers will be in full compliance with the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA

I understand my insurance will be billed for services provided by CHI St. Vincent Hot Springs at Lions Health and Wellness. I authorize the provider to use my signature for all insurance submissions.

I understand my insurance will be billed for services provided by CHI St. Vincent Hot Springs at Lions Health and Wellness. I authorize the provider to use my signature for insurance submissions.

I understand all information regarding services provided in Lions Health and Wellness will be shared with my primary care physicians as applicable.

I understand that CHI St. Vincent Hot Springs providers are located on the Jessieville Campus, and it may be necessary for a student to be transported. I give permission for my child to be transported via a school bus or other mode of transportation by an employee of the Jessieville School District to/ from Lions Health and Wellness as needed.

I understand that CHI St. Vincent Hot Springs providers are located on the Jessieville Campus, and it may be necessary for a student to be transported. I give permission for my child to be transported via a school bus or other mode of transportation by an employee of the Jessieville School District to/ from Lions Health Wellness as needed.

Patient Name

Responsible Party Printed Name

Responsible Party Signature

*Every attempt will be made to notify a parent/guardian by phone before the student receives any services at Lions Health and Wellness.