Shalom SBC Consent to Treat 24-25 English

Informed Consent for School-Based Health Clinic Services as provided by Shalom Health Care Center Inc. for 2024-25 School Year
Attention Parents/Guardians:

Your student's school and Shalom Health Care Center have partnered to operate a school-based health clinic in the school building. The goal is to help your family by providing these medical services for students while they are in school, assisting your child's physician with their healthcare needs, and providing access to high quality healthcare for those who do not have any healthcare services.

Our clinics are staffed with Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Advanced Practice Providers (APPs) such as Nurse Practitioners (NPs) or Physician Assistants (PAs An APP has a Master's degree or higher, and has been trained and licensed by the state to diagnose and treat. Our services are not intended to replace your child's primary care provider.

In accordance with Indiana State Law, all families wishing for their students to receive health services from Shalom School-Based Clinics (SBC) must have the student's Parent or Legal Guardian sign and submit a Consent to Treat form and complete a brief medical history each school year. This information provides our medical staff with the most up-to-date information for your child. Any information given will remain confidential as part of your child's medical record. The consent form will be invalid if any portion of the form is not fully complete.

Important:
- This consent is accepted at any school with a Shalom School-Based Clinic.
- This consent is valid for the entire 2024-25 school year (July 1, 2024, to June 30, 2025).
- Parents/Guardians may provide a written request to withdraw consent and treatment at any time.
- Parents/Guardians are responsible to notify Shalom clinic staff of any changes to the student's health history, or guardianship and/or demographic information.
- This school-based clinic program is provided at no cost to you or your family. However, to ensure our ability to continue to offer school-based clinic services and care for your child, Shalom will bill for services and collect from any third-party insurance your child may have. For this reason, we require your health insurance information be provided in order to provide services. Families will not receive a bill for any services provided in the school-based clinics.
Thank you for your cooperation and allowing us the privilege to participate in your child's health care needs.

Notice of Privacy Practices Summary
This summary describes how Shalom uses and shares your child's information and how you may acquire copies of this information. The full Notice of Privacy Practices is available at www.shalomhealthcenter.org as well as each of our clinics. We may use or share your child's information for the following:
- Treatment - such as discussions of your child's care amongst the medical staff
- Payment - such as billing insurance for services provided to your child.
- Operations - such as working to improve our quality of care, advertising services provided, etc.
- Other ways - such as mandatory disease reporting to county and state health officials, responding to court requests, appointment reminders, test result letters, etc.
Exceptions

Different laws may apply to mental health, family planning, drug and alcohol and AIDS/HIV treatment. Any other reasons for use or sharing of your child's health information will be completed only with your specific written permission or as required by law.

Regarding your child's health information, you have the following rights:
- Requesting restrictions on how your child's information is shared. Shalom is not required to agree to requested restrictions but will notify you if we cannot accommodate your request.
- Acquire and inspect a copy of your child's health record.
- Ask that incorrect or incomplete information in your child's medical record be corrected.
- Ask that we contact you by mail or phone to an alternate address and/or phone number.
- Change your mind if you previously granted sharing/use of your child's information for reasons other than those listed above.
- Receive a list of the times we shared your child's information. This list will only contain the times that the law requires us to record.
Changes

As we serve our patients, we may change how we handle your child's information. If we make any changes, we will give you a new notice the next time you visit our clinic. You may call or write at any time to check if we have made any changes.

Complaints

If you believe that your privacy rights have been violated, you may file a complaint with Shalom's Privacy Officer. You may also file a complaint with the U.S. Department of Health and Human Services. Your care will not be affected in any way if you choose to file a complaint.
Please address questions or complaints to

Shalom Privacy Officer

3400 Lafayette Road, Suite 200

Indianapolis, IN 46222

(317) 291-7422

I give permission for (Patient's Full Name)* (Date of Birth)*
to receive health services from the school-based clinic (SBC) at my child's school during the 2024-25 school year.(Consent in effect from July 1, 2024, to June 30, 2025.) I understand that the school-based clinic provider does not replace my child's Primary Care Provider and cannot take care of all my child's health care needs.
1. have read the information provided regarding the school-based health clinic and the release of information and I understand what services the clinic will and will not provide. My consent will allow my child to receive health services while they are a student at any school with a Shalom SBC during the effective period. I understand that if I chose to cancel these services, I must provide the request in writing. It will be my responsibility to notify the clinic staff regarding changes in guardianship, contact information, and health history.
2. Information Privacy: I have been informed that Shalom has prepared a detailed NOTICE OF PRIVACY PRACTICES regarding my child's personal health information. I understand that the terms of the notice may change, and current notices will be available on Shalom's website and facilities.
3. Release of Information: I understand the services provided by the school-based health care clinic are confidential. The clinic will use and disclose my child's personal health information to provide treatment and or improvement of health care operations. My child's information may be shared with my child's physician/provider, appropriate school staff, or with my child's insurance provider for legitimate purposes.I authorize the release of my child's medical information to other providers who may have my child as a patient. I also authorize the use of information from my child's medical record for the purposes of medical care, treatment, clinic administration and evaluation. In addition, I give my consent to the clinic staff to look at, and update my child's school health record, including immunizations.
I acknowledge I have received a copy of Shalom Health Care Center Inc Notice of Privacy Practices Note An electronic signature like an in person signature is valid and sufficient to give consent.*
(Parent/Guardian Initials)
Signature of Parent/Guardian*

Clear
Printed Name of Parent/Guardian*
Date*

MonthDayYear
Relationship*
INSURANCE INFORMATION (REQUIRED SECTION)

Insurance coverage is NOT required to be seen in a Shalom clinic; however, this section MUST be completed.
MedicaidPrivate Insurance
Medicaid Type
Medicaid Type Member ID
Private Insurance
Private Insurance Member ID
Group Number
Name of Policy Holder

First NameLast Name
Name of Policy Holder
Policy Holders DOB

MonthDayYear
No InsurancePlease refer my family to a free insurance navigator to help with all options available
*As a Federally Qualified Health Center, Shalom is required to attempt to collect yearly household size and income information in order to continue receiving special funding for our school-based clinics. Please support our programs by providing the following information:
Choose not to disclose
Number of people living in home
Total household income
SERVICES WILL NOT BE PROVIDED WITHOUT A SIGNED PARENTAL/GUARDIAN CONSENT AS REQUIRED BY THE INDIANA STATE LAW.

Informed Consent for School-Based Health Clinic Services as provided by Shalom Health Care Center Inc. for 2024-25 School Year

Important:

Notice of Privacy Practices Summary

Exceptions

Changes

Complaints

Please address questions or complaints to

INSURANCE INFORMATION (REQUIRED SECTION)

PATIENT INFORMATION FOR 2024-25 SCHOOL YEAR

DAYTIME & EMERGENCY CONTACTS

Contact #1

Contact #2

Contact #3

Emergency Contact

HEALH INFORMATION

For office use only