SSHC Consent Form

Somersworth Student Health Center Enrollment and Consent Agreement Information
Please read the following agreement and initial where prompted before filling and signing the form below.

A parent or guardian must sign a consent form for any student, regardless of age, to receive services at the Somersworth Student Health Center. The Somersworth Student Health Center complies with all federal and state privacy regulations (HIPAA). Student health information will only be used for treatment and billing purposes.
Initials
I give consent for my child or student’s health information to be shared with their primary care provider.
Initials
I understand that I am financially responsible for the services provided to my child.
Initials
I authorize the release of my child or student’s information regarding the care, services or treatment received to any third-party payers for the purposes of billing.
I understand that:
- My student or child will not receive services at the Somersworth Student Health Center unless a consent form is on file, except in an emergency as allowed by the laws of the state of New Hampshire.
- I may withdraw or discontinue the consent given in this form by submitting a request in writing at any time while my child or student is enrolled in the Somersworth Public School system.
Somersworth Student Health Center Enrollment and Consent Agreement
By signing and agreeing to this form, I authorize and give consent for Goodwin Community Health to provide the following services to my child or student at the Student Health Center:*

Medical care (acute visits for illness or injuries, sports physicals, wellness visits, sexual/reproductive health, vaccinations).Vaccinations only (no medical visits)Mental health counseling (currently open to Somersworth High School students only)
If you consented to medical care above but would prefer that your student NOT receive sexual/reproductive health care and/or vaccines, please indicate below.

I DO NOT wish my student to receive sexual/reproductive health care.I DO NOT wish my student to receive vaccines.
Student's Legal Name*
Date of birth*

MonthDayYear
Date
Sex assigned at birth*
Name of Insurance Plan
Insurance ID Number
Primary Care Provider
Provider Practice Name
Provider Phone
Parent/Guardian Name*
Phone Number*
Home Address*
ParentGuardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Somersworth Student Health Center Enrollment and Consent Agreement Information

Somersworth Student Health Center Enrollment and Consent Agreement