Parent Consent Form for School-Based Health

PARENT CONSENT FORM

INFORMED CONSENT FOR SCHOOL-BASED HEALTH SERVICES
The following services are provided at the school-based health center:
- PHYSICAL EXAMS AND SPORTS PHYSICALS
- HEALTH CARE FOR ILLNESSES & INJURIES
- MEDICALLY-PRESCRIBED LABORATORY TESTS
- HEALTH EDUCATION FOR STUDENTS AND PARENTS
- IMMUNIZATIONS
- VISION SERVICES BY REFERRAL
- REFERRAL FOR SPECIALTY CARE
- BEHAVIORAL HEALTH SERVICES
If you want your child to receive services at the school-based health center, even if your child is an existing AccessHealth patient, please read this form carefully, complete the questions, and sign.

CHILD'S INFORMATION

PARENT CONSENT FORM
NAME:
Your child's name as it appears on birth certificate
BIRTH DATE:
Your child's birthdate - MM/DD/YYYY
SCHOOL ATTENDING:
Name of the school your child will be attending
GRADE:
Your child's grade level
SEX:
Your child's sex
SOCIAL SECURITY NUMBER:
Your child's social security number - ##-##-####
RACE:
Your child's race
SPECIAL NEEDS:
Does your child have any special needs - physical handicap, learning disabilities, dietary needs, etc?

PARENT/GUARDIAN INFORMATION

PARENT CONSENT FORM
NAME:
Parent/Guardian with legal right to make healthcare decisions for the patient/student
RELATIONSHIP:
Parent/Guardian relationship to child
BIRTH DATE:
Parent/Guardian Birth Date - MM/DD/YYYY
ADDRESS:
Parent/Guardian Mailing Address
CITY, STATE, ZIP:
Parent/Guardian City, State, & Zip Code
SOCIAL SECURITY:
Parent/Guardian Social Security Number - ###-##-####
HOME PHONE:
Parent/Guardian Home Phone Number - (555) 123-4567
CELL PHONE:
Parent/Guardian Cell Phone Number - (555) 123-4567
WORK PHONE:
Parent/Guardian Work Phone Number - (555) 123-4567
EMAIL ADDRESS:
Parent/Guardian Email Address

EMERGENCY CONTACT INFORMATION

PARENT CONSENT FORM
NAME:
NOT USED FOR MEDICAL DECISION MAKING - Please list an adult relative or friend that will know how to contact you in case of an emergency.
RELATIONSHIP:
Emergency contact relationship to child
PHONE:
Emergency contact phone number - (555) 123-4567

CONSENT TO TREAT

PARENT CONSENT FORM
The above information is accurate and complete to the best of my knowledge. I have completely disclosed all known allergies, chronic illness, prior medications or drugs that have resulted in adverse reactions, and current medications with respect to my child.

By signing below, I authorize my child to be seen at the school-based clinic and consent to all services listed on page one (PHYSICAL EXAMS AND SPORTS PHYSICALS; HEALTH CARE FOR ILLNESS AND INJURIES; MEDICALLY-PRESCRIBED LABORATORY TESTS; HEALTH EDUCATION FOR STUDENTS AND PARENTS; IMMUNIZATIONS; VISION SERVICES BY REFERRAL; REFERRAL FOR SPECIALITY CARE; BEHAVIORAL HEALTH SERVICES) except what I have listed below.
I DO NOT WANT MY CHILD TO RECEIVE THE FOLLOWING SERVICES:
I, the parent/guardian of said student, give consent for my child to receive services at the school-based clinic. I understand that this consent form will be good until my child leaves this school or until I provide the health center staff with written directions otherwise.
PARENT/GUARDIAN SIGNATURE

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DATE:

MonthDayYear
RELATIONSHIP:
Signers relationship to child

PRIVACY PRACTICES

PARENT CONSENT FORM
All healthcare information is confidential. By signing below you are giving the school-based clinic, school’s nurse and your child’s regular doctor (if applicable) permission to communicate and share medical information regarding your child’s medical condition on an as needed basis with the understanding that this information will continue to be treated in a confidential manner.

I authorize AccessHealth to access medication history and share my child’s immunization record with West Virginia State Wide Immunization Information System. I agree to Health Data Sharing.

The center may release information regarding treatment to third party payors for billing purposes.

The center may photograph your child to be used for their Electronic Medical Record only.

I acknowledge that I have received a copy of the Notice of Privacy Practices.
PARENT/GUARDIAN SIGNATURE:

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DATE:

MonthDayYear

INSURANCE BILLING

PARENT CONSENT FORM
AccessHealth will subsidize all insurance co-pays for students that utilize our clinic services at the school-based site. All insurances will be billed for services utilized at the clinic. You will receive a monthly bill for any balances due.

I authorize AccessHealth to bill my insurance carrier.
PARENT/GUARDIAN SIGNATURE:

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DATE:

MonthDayYear

INSURANCE INFORMATION

PARENT CONSENT FORM
NAME:
CHILD'S LEGAL NAME
DATE:

MonthDayYear
TODAY'S DATE
PHONE:
CHILD'S PHONE NUMBER - (###) ###-####
BIRTH DATE:
CHILD'S BIRTH DATE - MM/DD/YYYY
SOCIAL SECURITY:
CHILD'S SOCIAL SECURITY - ###-##-####
ADDRESS:
CHILD'S ADDRESS - 123 Any Street, City, WV 12345
COVERED BY AN INSURANCE PLAN? If yes, please fill in the appropriate following section.

YESNO
PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD

Cancelof
PRIVATE INSURANCE INFORMATION
NAME:
INSURED PARENT/LEGAL GUARDIAN NAME
BIRTH DATE:
INSURED PARENT/LEGAL GUARDIAN BIRTH DATE - MM/DD/YYYY
SOCIAL SECURITY:
INSURED PARENT/LEGAL GUARDIAN SOCIAL SECURITY - ###-##-####
ADDRESS:
INSURED PARENT/LEGAL GUARDIAN ADDRESS IF DIFFERENT FROM CHILD - 123 Any Street, City, WV 12345
EMPLOYMENT:
INSURED PARENT/LEGAL GUARDIAN PLACE OF EMPLOYMENT
COMPANY:
INSURANCE COMPANY NAME AND COMPLETE ADDRESS
PHONE:
INSURANCE COMPANY PHONE NUMBER
GROUP:
INSURANCE COMPANY GROUP NUMBER:
ID:
INSURANCE COMPANY ID NUMBER:
TO:
INSURANCE COVERAGE EXPIRE DATE - MM/YYYY
FROM:
INSURANCE COVERAGE START DATE - MM/YYYY
MEDICAID INFORMATION
PLEASE SELECT YOUR CHILD'S MEDICAID CARRIER

UNISYSUNICARECARELINK
MEDICAID ID:
MEDICAID ID#
CARELINK ID:
MEMBER ID# (CARELINK)
PCP/HMO:
PCP/HMO PROVIDER NAME
PHONE:
PROVIDER PHONE NUMBER (###) ###-####
CHIP INFORMATION (CHILDREN'S HEALTH INSURANCE PROGRAM)
NAME:
NAME LISTED ON CARD
BIRTH DATE:
BIRTH DATE - MM/DD/YYYY
ID:
ID OR PIN# ON CARD
GROUP:
GROUP #
FROM:
START DATE - MM/YYYY
TO:
END DATE - MM/YYYY
HOUSEHOLD:
ENTER NUMBER OF PEOPLE IN HOUSEHOLD
INCOME:
ENTER GROSS MONTHLY INCOME
Should be Empty:

	Medication/Dose	Reason	Duration	Prescribing Physician
1)
2)
3)

	YES	AGE
ALLERGIES
ANEMIA OR BLOOD DISORDERS
ASTHMA
BLADDER OR KIDNEY INFECTIONS
CANCER
CHICKEN POX
DIABETES
ENDOCRINE/GLAND DISEASE
HEPATITIS
HEADACHES/MIGRAINES
MONONUCLEOSIS
PNEUMONIA
RHEUMATIC FEVER/HEART DISEASE
SCOLIOSIS
SEIZURES
SEVERE ACNE
SPORTS INJURIES OR FRACTURES
THYROID DISEASE
TUBERCULOSIS
ULCER OR DIGESTIVE PROBLEMS
MENTAL ILLNESS OR DEPRESSION

	YES	RELATIONSHIP
ALCOHOLISM/DRUGS
ALLERGIES/ASTHMA
ARTHRITIS
BIRTH DEFECTS
BLOOD DISORDERS/SICKLE CELL ANEMIA
DIABETES
ENDOCRINE/GLAND DISEASE
HEART ATTACK
HIGH CHOLESTEROL
HIGH BLOOD PRESSURE
KIDNEY DISEASE
LUNG DISEASE/TUBERCULOSIS
MENTAL HEALTH/DEPRESSION
INTELLECTUAL DISABILITY
OBESITY
SEIZURES/EPILEPSY
STROKE BEFORE AGE 55

PARENT CONSENT FORM

CHILD'S INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT INFORMATION

CHILD HISTORY

FAMILY HISTORY

CONSENT TO TREAT

PRIVACY PRACTICES

INSURANCE BILLING

INSURANCE INFORMATION