Ripley School-Based Health Services

Ripley School-Based Health Services

2025-2026
Hello BlueJays!

We are so excited to be starting our sixth year, offering school-based health services for RULH families. We welcome you and your child to be part of our PrimaryPlus-Ripley School Based Health Center. Our sites offer students, parents, faculty, and the entire community access to primary care and counseling services. PrimaryPlus is a Federally Qualified Health Center with over thirteen service locations throughout the region. Our health center operates year-round and during the school year we are readily available to care for your child(ren) during school hours (upon completion of consents and medical history). Parents/Guardians are always welcome at the appointments but are not required to be present as long as we have received consents and medical history.

Consent packets are for school-based Primary Care/Telemedicine ONLY. Counseling Services are referral based OR a parent/guardian can call to schedule for this service. Note: All dental services at Ripley have been paused, as we work to recruit a new dentist.

About School-Based Medical Services:  Family Health Nurse Practitioner, Carissa Kirk, APRN, provides family health services at PrimaryPlus-Ripley. School-based services are designed to be an added resource to parents and IS NOT designed to replace your child’s pediatrician or routine medical provider—although we are happy to establish care with you if you or child does not have a routine medical provider.   As a school-based health center, the goal is to provide a convenient, quality healthcare evaluation upon parental consent when your child has any minor sickness such as earache, throat infection, eye infection, skin irritation, cold, runny nose, etc. Parents/guardians can be included in a telehealth visit of their child’s appointment upon request or are welcome to be in-person for the visit.

Consent for School-Based Services: Attached are the consent forms for the 2025-2026 school-based services. Parents/guardians may select which services they would like their child to participate. Note: If the student is already a patient of PrimaryPlus, they will STILL need to complete the forms because school-based services require added information and must be completed once a year—so last year’s consent forms are no longer valid.

This partnership is geared towards ensuring happy, healthy kids and creating access to quality care for families of the region! You can find a list of frequently asked questions regarding school-based health and the PrimaryPlus Notice of Privacy and HIPAA Practices on the school website or at www.primaryplus.net. Please feel free to contact the PrimaryPlus-Ripley team at 937-744-4343 if you have any questions. Our office hours are Monday through Friday 8 am to 5 pm.

Many Well Wishes for a Great School Year,

The PrimaryPlus Team

Consent packets will need to be completed and returned by Friday, September, 5th.

Students that return completed packets will have an opportunity to win

1 of 3 $100 gift cards provided by PrimaryPlus!

Service Consent

Please read carefully, COMPLETE FORM, SIGN, and DATE. Please notify PrimaryPlus if there are any changes in health information or guardianship. PrimaryPlus collects new consents each school year. If your child is already a patient of PrimaryPlus and you wish to participate in school-based health services, forms must be completed.

Consent packets are for school-based Primary Care Services. Counseling Services are referral based OR a parent/guardian can call to schedule for this service.
Student First Name*
Student Last Name*
Birth Date*

MonthDayYear
Date
Social Security Number
I give my consent for my child to receive the following services at PrimaryPlus School Based Health Center:*

Nurse Practitioner /Telehealth Services (NP/Telehealth services for acute illness, wellness exams, sports physicals, etcNo Services at this time
Please sign below.

Note that if the parents of the above stated child have joint custody, signatures of both parents are required for consent to treat, please be sure to sign below.

Patient/Student Signature is ONLY allowed if 18 or OLDER. If under 18, MUST be signed by parent/guardian.
Parent or Guardian Signature*

Clear
Parent or Guardian Printed Name*
Date*

MonthDayYear
Date
Parent or Guardian Signature

Clear
Parent or Guardian Printed Name
Date

MonthDayYear
Date
PrimaryPlus shall provide a copy of its Notice of Privacy and HIPAA Practices upon my request, which is also available at www.primaryplus.net.

PrimaryPlus School-Based Health Registration Form
Patient Information

Please Complete the following information about your child.
Student's School*
Sex Assigned at Birth:*

MaleFemale
Parent/Guardian Information:

Parent/Guardian #1
Name:*
Address*

Street Address or PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
State*
Zip Code*
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email
example@example.com
Parent/Guardian #2 (if applicable)
Name:
Home Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email
example@example.com
Emergency Contact (Other than Guardian)
Name
Phone
Who is your child's Primary Care Physician?
Phone
Fax
Would you like your child's visit notes to be sent to their Primary Care Physician?

YesNo
*PrimaryPlus is happy to share records of your child's visit with their pediatrician or regular primary care provider.
Preferred Pharmacy Name
Phone
INSURANCE INFORMATION

Please provide insurance information if unable to take photo of insurance card.
Take Photo of front of insurance card
Take Photo of back of insurance card
Primary Insurance Company Name
ID Number
Group Number
Name of Policy Holder
Policy Holders Date of Birth

MonthDayYear
Date
Relationship to Patient
Check this box if you do NOT have medical insurance. You may be contacted by our Community Health Worker.

Consent to Treat

Physicians of: Lewis County Primary Care Center, Inc./ DBA PrimaryPlus
I, _________ (parent/guardian) acting on behalf of ________ (student/patient) who is suffering from a condition requiring medical, podiatric and/or dental care.

I agree to allow this care to be received. It may include routine diagnostic and medical treatment that the attending physician(s) or others of the health center medical staff consider necessary. Services could include treatment for illness or injury including over the counter medications or necessary prescriptions, well child exams, appropriate immunizations, and appropriate behavioral evaluations--unless emergency services are needed.

2. I understand that the practice of medicine and surgery is not an exact science, and that diagnosis and treatment may involve risks of injury or even death. I acknowledge that no guarantees have been made to me about the result of examination or treatment in this

3. I understand that:

a) Normally, except under emergency or extraordinary circumstances, no important procedures are performed upon a patient unless and until he or she has had an opportunity to discuss them with the physician or other health professionals to the patient's satisfaction.

b) Each patient has the right to agree or refuse to agree to any proposed procedure or therapeutic course; and

c) No patient will be involved in any research or experimental procedure without his or her full knowledge and agreement.

4. I realize that there are medical, nursing and other health care personnel at this health center who are still in training. I understand that they may be present during my care unless I request them not to be present.

5. This form has been fully explained to me, and I am satisfied, and I understand its content and significance.

6. Once the student's completed consent and history are received, PrimaryPlus can begin caring for your child for approved services during school hours. Attempts will be made to notify the parent/guardian of your child's appointment and to see if they wish to attend the visit. If no contact is made and all consents are in place, PrimaryPlus will continue the appointment as needed and contact the parent with follow-up information following the appointment including sending home a copy of the care summary.
ParentGuardians Signature*

Clear
Parent/Guardian Name:*
Date*

MonthDayYear
Date
Note: Patient/Student Signature is ONLY allowed if 18 or OLDER

I HEREBY CONSENT FOR THE FOLLOWING PERSON/PERSONS TO BRING MY UNDERAGED CHILD TO LEWIS COUNTY PRIMARY CARE CENTER, INC. dba PRIMARYPLUS FOR TREATMENT.

(Please list name and relationship to child)
Name
Relationship to Child:
Name
Relationship to Child:
Name
Relationship to Child:
Parent or Legal Guardian Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Ripley School-Based Health Services

INSURANCE INFORMATION

Medical History

Dental History

Other Information

Consent to Treat