• School Parental Consent Form

    Oral Health Clinic Program - School Parental Consent Form

  • STUDENT INFORMATION

  • Date of Birth

  • PARENT/GUARDIAN INFORMATION

  • Mother

  • Father

  • Legal Guardian, If Applicable

  • Relationship of legal guardian to student

  • Contact Information for Parent or Guardian

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Additional Emergency Contact

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

  • Does your child have Medicaid?*
  • Does your child have Child Health Plus?*
  • Which Plan?
  • Does your child have coverage through an employer based plan or other type of health insurance?*
  • Format: (000) 000-0000.
  • Birth Date of Insured Adult
     / /
    2 digit month, 2 digit day, 4 digit year

  • Services will be provided to your child regardless of whether or not your child has health insurance, at no cost.

  • PARENTAL CONSENT FOR SCHOOL-BASED HEALTH CLINIC SERVICES

  • I understand that my child will be receiving oral health services and my signature provides consent for my child to receive services provided by the OHCP for as long as my child is enrolled in the School District. I may withdraw my consent at any time by written notice to the OHCP. I understand that I will report any significant changes in my child’s health to the provider.

    NOTE: By law, parental consent is not required for students who are 18 years or older or for students who are parents or legally emancipated. My signature indicates I have received a copy of the Notice of Privacy Practices.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION

  • I have read and understand the release of health information on page 2 of this form. My signature indicates my consent to release health information as specified.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • CONSENT FOR SCHOOL-BASED ORAL HEALTH CLINIC SERVICES

  • I consent for my child to receive oral health care services provided by the State-licensed health professionals of the OHCP as part of the school oral health program approved by the New York State Department of Health for as long as my child is enrolled at school. I may withdraw my consent at any time by written notice to the OHCP. I understand that confidentiality between the student and the oral health clinic provider will be ensured for specific service areas in accordance with the law, and that students will be encouraged to involve their parents/guardians in counseling and oral care decisions. School-Based Oral Health Clinic Services may include, but are not limited to, preventative oral health services, restorative services, and emergency procedures. Preventative oral health services include, but are not limited to, comprehensive dental exams, dental hygiene treatments, x-rays, sealants and fluoride treatments. This may also include the application of Silver Diamine Fluoride on back teeth to halt the progression of cavities (Silver Diamine Fluoride may discolor any cavities resulting in a brown or black color For services other than comprehensive dental exams and preventative oral health services, the OHCP shall notify the parent/guardian of the services and treatments that need to be provided and such services will be referred out to a specialist..

  • HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION

  • My signature on the reverse side of this form authorizes the release of health information. This information may be protected from disclosure by federal privacy law and state law. By signing this consent, I am authorizing health information to be released to the Board of Education, which may include school nurses, because it is required by law, and to protect the health and safety of the student, or in order to process a claim with my child’s insurance provider. Upon my request, the facility or person disclosing this health information must provide me with a copy of this form. Parents are required by law to provide certain information to the school, like proof of immunization. Failure to provide this information may result in the student being excluded from school. My questions about this form have been answered. I understand that I do not have to allow the release of my child’s health information, and that I can change my mind at any time and revoke my authorization by writing to the OHCP. However, after a disclosure has been made, it cannot be revoked retroactively to cover information released prior to the revocation. I authorize the OHCP to release specific health information on the student named on the reverse page to the Board of Education. I consent to the release from the OHCP to the School District and from the School District to the OHCP, of health information outlined below in order to meet regulatory requirements and to ensure that the District has information needed to protect my child’s health and safety. I understand that this information will remain confidential in accordance with Federal and State law, including HIPAA and NY Education Law §2-d:

    Conditions which may require emergency

    Conditions which limit a student’s daily activity

    Diagnosis of certain communicable diseases (not including HIV infection/STI and other confidential services protected by law

    Health insurance coverage

    My signature on page 1 of this form also gives my consent to the OHCP to contact other providers that have examined my child and to obtain insurance information.

    The Release of Information is authorized from the date that form is signed until the student is no longer enrolled in the School Based Oral Health Clinic Program or until revoked, whichever is earlier.

    Patient Rights and Privacy Policy shall be provided by the OHCP, as applicable by law.

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