Scioto Valley School-Based Health Center Intake Forms

Valley View
COMMUNITY ACTION COMMITTEE OF PIKE COUNTY

Valley View Health Centers Scioto Valley School-Based Health Services Enrollment Packet Welcome to Valley View Health Centers School-Based Health Services (SBH) School-based health centers offer the students, teachers, families, and community members access to medical care when it might otherwise not be available or convenient. We operate year-round and during the school year we can coordinate NO-COST transportation from the schools in the district where Scioto Valley Local operates, to the health centers and back. Parents/guardians are always welcome at the appointments, but are not required to be there.

A Valley View Health Center (VVHC) staff member will contact you after your child's first appointment to set up a time to discuss your child's treatment plan and answer any questions you may have. Once the student's completed consent and history are received, we will begin scheduling appointments for approved services. You will receive a notice of the student's appointment time by phone. If we do not receive a request to change the appointment, we will proceed as scheduled. Complete the required documents and return to school with the student or drop off at the health center. Scheduling may be delayed if there are missing documents or information is illegible. Please feel free to contact us during regular business hours at 740-289-1638 if you have any questions.
STUDENT INFORMATION & CONSENT FOR SERVICES
Todays Date*

MonthDayYear
Date
Name*

Students First NameStudents Last Name
MI*
Students Date of Birth*

MonthDayYear
Date
Students Current School*
Students Current Building
Students Current Grade*
I consent to transportation services. This service includes but is not limited to; transport to and from the SVLSD building to the health center. I, the parent or guardian of the above-named student, release SVLSD from any and all liability to personal injury or damage resulting from the transportation to or from the school for these purposes. I give my informed consent for my child to participate in the following services: Please check which services you wish your child to participate in:
Types of Services Available:*

ALL ServicesMedicalBehavioral HealthTelehealthCase Management*Dental
*If services are not provided by School-Based Health Center, arrangements will be made to an alternative Valley View Health Center.
Consent for Vaccinations*

YES - I wish to have ALL vaccines available for my student.NO - I wish to have ONLY the vaccines selected below
REQUIRED Vaccines *for school attendance in Ohio

DTaP/Tdap/TdMeningococcal/Men BMMRVaricellaPolioHepatitis B
RECOMMENDED Vaccines *not required to attend School by Ohio Department of Health

Influenza (Flu)HPVHepatitis APneumococcalHib
By signing this consent, a copy of which will be provided to me, I agree to the terms and conditions regarding Authorization to Release and Share Information and the Assignment of Insurance Benefits. I also acknowledge that I have received the Notice of Privacy Practices and that Valley View Health Centers Notice of Privacy Practices is available upon my request where services are provided. I can also view the Notice of Privacy Practices online at https://valleyviewhealth.org.

I understand that this consent will remain valid throughout the current 12-month academic year commencing August 1, unless revoked. I understand that I may revoke this consent for treatment at any time by making a written request to VVHC have me/my child removed from services. I have reviewed the services summary information attached to this consent, and I understand the services available. It is my responsibility to tell VVHC about changes in insurance coverage, and to notify School District and VVHC with all updates or changes to my child's health condition(s), immunization records, or medications. I will be notified of any services my child receives (subject to applicable law), as well as any abnormal findings and/or further treatment recommendations. For questions related to any services my child receives I understand that I should call the phone number listed on the After Visit Summary which will be sent home with my child.

Authorization to Release Medical Information: I hereby authorize VVHC and Scioto Valley Local Schools to share/release/exchange information with school nurses, school counselors, school social workers and/or school administrators about my/my child's physical and/or mental condition, including, but not limited to, information regarding services provided to my child at school for treatment purposes, care coordination and/or educational purposes. I understand this information will be kept confidential. I also hereby authorize VVHC to share/release/exchange all such information with my doctors, my referring doctors, or referring/referral health care providers; and/or to any insurance company or organization that helps pay my bill. VVHC may also give information to any welfare organization, to which I have applied or may apply for aid. Administered immunizations will be entered into the statewide immunization information system, Ohio ImpactSIIS.

I understand that School District is covered under the federal regulations that govern the privacy of educations records and that any personal health information disclosed under this authorization may be protected by those regulations. Re-disclosure of alcohol and drug abuse information is protected by Federal Confidentiality Rules (42 CFR Part 2) without written consent of the person to whom it pertains or as otherwise permitted. Federal Rules also restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse patient (52 FR 21809, June 9, 1987:52 FR 41997, November 2, 1987 My/my child's records are protected and can only be accessed by authorized users with restricted access. I understand that this authorization will remain valid throughout my child's enrollment at his or her School District for the current 12 month academic year commencing August 1, unless I revoke this authorization. I may revoke this authorization at any time by providing written notice of my intent to revoke to School District and/or VVHC. I understand that I am not required to sign this authorization form and the VVHC will not condition treatment, payment, enrollment, or eligibility for benefits on this signed authorization. The health information used and/or disclosed as a result of this authorization may be subject to re-disclosure by the person or entity receiving such information. At that point, it is no longer protected by the federal privacy regulations. Neither VVHC nor my child's School District is responsible for the use of information, in whole or in part, by third parties. This authorization is given without promise of compensation. I have received a copy of this form and I understand that I have the right to inspect or copy any health information disclosed. This authorization included the use and/or disclosure of information, concerning HIV testing or treatment of AIDS or AIDS-related conditions, any drug or alcohol abuse, drug-related conditions, alcoholism, and/or psychiatric/psychological conditions to the above-mentioned entity.
Students Name*
ParentGuardian Printed Name*
Parent Guardian Signature*

Clear
Date*

MonthDayYear
Date
If student 18 Student Signature*

Clear
Date*

MonthDayYear
Date
Last Name*
First Name*
Mailing Address*
City*
State*
Zip*
County*
SSN*
Email Address*
example@example.com
Home Phone*
Work Phone*
Sex at Birth:*

MaleFemalePrefer Not to Say
Marital Status*

SingleMarriedDivorcedWindowedSeparatedPartnerOther
Are You Homeless*

YesNo
If Yes, Where Are You Staying?

Homeless ShelterTransitionalDoubling UpStreetOther
Are You a Migrant or Seasonal Worker?*

YesNo
Are You a Veteran?*

YesNo
Race*

Asian IndianChineseFilipinoJapaneseKoreanMiddle EasternNative HawaiianOther Pacific IslanderGuamanian or ChamorroSamoanBlack or Africian AmericanNorthern AfricianAmerican Indian / Alaska NativeWhiteMore than One RaceChoose NOT to Disclose
Ethnicity*

Mexican, Mexican American, ChicanoPuerto RicanCubanAnother Hispanic, Latino, or Spanish OriginHispanic, Latino/Spanish CombinedNot Hispanic, Latino, or SpanishChoose NOT to Disclose
Emergency Contact*
Relationship*
Emergency Phone
Preferred Pharmacy*
City*
Pharmacy Phone
Primary Insurance Company Name*
If no health insurance, please enter "NA"
Secondary Insurance Company Name
Policy Identification Number*
If no health insurance, please enter "NA"
Policy Identification Number*
If no health insurance, please enter "NA"
Policy Holder Name*
If no health insurance, please enter "NA"
Policy Holder Name*
If no health insurance, please enter "NA"
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder SSN*
If no health insurance, please enter "NA"
Patients Relationship to Policy Holder*
If no health insurance, please enter "NA"
Policy Holder SSN*
If no health insurance, please enter "NA"
Patients Relationship to Policy Holder*
If no health insurance, please enter "NA"
Responsible Party

Responsible Party Must Be Provided if Patient is Under 18
Name Last First MI*
Date of Birth*

MonthDayYear
Date
SSN*
Mailing Address*
City State Zip*
Phone*
Relationship to Patient*
Valley View Health Centers is a Federally Qualified Health Center. We are required to collect income and other demographic information of our patient population. All information is Confidential, and we are only required to report numbers. RelationshipAgeMonthly IncomeEmployed
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Valley View Health Centers is a Federally Qualified Health Center.
We are required to collect income and other demographic information of our patient population. All information is Confidential, and we are only required to report numbers.
Who Lives in Your Residence
Please complete the following information if you choose to apply for the sliding fee discount.

To apply for the sliding fee at Valley View Health Centers, you must provide proof of household income, including all gross income generated by family members related by blood, marriage, or adoption.

Acceptable proof includes:
• Paystubs covering four weeks (four if paid weekly, two if paid bi-weekly)
• Most recent year’s income tax return (for self-employed individuals)
• A written statement from your employer
• Unemployment check stub
• Social Security letter or form SA-1099-1042S
Income Information*
Person 1: How Often Paid*

WeeklyBi-WeeklyMonthlyNot Applicable
Person 2: How Often Paid*

WeeklyBi-WeeklyMonthlyNot Applicable
Other Sources of Income*

UnemploymentSocial Security InsuranceRetirementChild SupportInterest/InvestmentsOtherSocial SecurityNot Applicable
If your income is 0 we understand that you may need additional support Please provide information on how you are meeting your basic needs such as food clothing shelter and transportation We are here to help
Sliding Fee Scale By signing below, you confirm your application for the sliding fee scale and agree that Valley View Health Centers may verify your income. You also agree to reapply annually, report any changes in income, household size, or insurance coverage, and pay your copay at the time of service. Certain services or items may not be eligible for discounts. You certify that the information provided is correct.
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
I have been offered the opportunity to apply for the sliding fee scale. However, I Decline to do so at this time. I am aware that I can apply at any time.
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Please Initial

I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.I understand that I may opt out of the telehealth visit at any time. This will not change my ability to receive future care at this office.
Please Initial

I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), and it is my responsibility to check with my insurance plan to determine coverage.
I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures. Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network. Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.

I agree that information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care.
communications by others.

I understand that medical information, including medical records, is governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records and copies of medical recordsI understand that I must take reasonable steps to protect myself from unauthorized use of my electronicThe healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.
SELECTIONELEMENTNOTSELECTEDI understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider

I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider.
I understand that electronic communications cannot be used for emergencies or time-sensitive matters.

I understand and agree that a medical evaluation via telehealth may limit my healthcare provider's ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider's recommendations-including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.
I understand and agree that a medical evaluation via telehealth may limit my healthcare provider's ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider's recommendations-including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.

I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment alcohol, drug dependence, etcI understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications.
I understand and agree that a medical evaluation via telehealth may limit my healthcare provider's ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider's recommendations-including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.

By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.
I understand and agree that a medical evaluation via telehealth may limit my healthcare provider's ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider's recommendations-including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.

I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider's office or to the existing emergency 911 services.
I understand I can reach the National Suicide Hotline by calling or texting 988.

I have been given a copy of this document. I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the
SELECTIONELEMENTNOTSELECTEDI have been given a copy of this document I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the opportunity to have questions answered to my satisfaction

Clear
opportunity to have questions answered to my satisfaction. For electronic communication between Community Action Committee of Pike County/Valley View Health Centers, staff, (patient's name
ParentGuardian Signature if 18 student signature

Clear
Date

MonthDayYear
Date
Relationship to Patient
I certify that I have explained the nature of this agreement to the patient/patient's legal representative. I have answered all questions fully, and I believe that the patient/legal representative fully understands what I have explained.
Healthcare Representatives Signature

Clear
Date

MonthDayYear
Date
Valley View
HEALTH HISTORY
Patient Name
Date of Birth

MonthDayYear
Date
Date of last physical exam head to toe

MonthDayYear
Date
Immunizations up to date

MonthDayYear
Date
Have you been hospitalized overnight in the past year? If YES, why? Have you had any surgeries in the past year? If YES, why?
Date of last complete dental exam

MonthDayYear
Date
Dentist Name
How often
How often
Have you ever felt faint or woozy after dental treatment?
YES
Date of last complete eye exam

MonthDayYear
Date
Do you have or had glasses in the past
Providers Name
Headaches with visionrelated tasks
Trouble seeing things up close?

MEDICATION (List all current medication: prescribed, over the counter, vitamins, inhalers and dosage, if known) DosageFrequency

Are you allergic to any of the following? Sulfa Drugs
List any other allergies or reactions
SURGICAL HISTORY: LIST ANY PAST SURGERIES/HOSPITALIZATIONS BELOW. NO PAST SURGERIES/HOSPITALIZATIONS

Name/Type of Surgery or Hospitalization
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS?
ADD/ADHD AIDS/HIV
Organ Transplant Osteoporosis Pacemaker/Defibrillator Psychiatric/Mental Health Condition

Arthritis Asthma Autoimmune Disease

Bladder/Kidney Problem Bleeding Disorder

Heart Valve Replacement Hepatitis High Blood Pressure High Cholesterol

Seizures/Epilepsy Sexually Transmitted Infection Skin Problems/Allergies
Any problem not listed
Muscle, Joint, Bone Problem Nervous System Disorder
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?
Do you take or have you taken any oral or IV medications for Osteoporosis? Such as Fosamax or Boniva? Are you pregnant or think you might be pregnant? Have you had any prosthetic joint replacements?

Are you undergoing or have you undergone chemotherapy or direct head/neck radiation?
TOBACCO USE
Have you ever smoked or used cigarettes, e-cigarettes, vape pens, or other tobacco products?
COMPLETE THE SECTION BELOW IF YOU HAVE EVER USED TOBACCO
Tobacco Status? (choose one) Current Every Day
Approximately how much tobacco do you use
How long have you used tobacco
Are you interested in quitting
Do you currently use marijuana or other recreational drugs? Are you in any type of drug/alcohol rehabilitation program?
Patient or ParentGuardian Signature

Clear
Witness
Date

MonthDayYear
Date
Provider
Date

MonthDayYear
Date
Valley View
PARENTAL CONSENT FOR TRANSPORTATION OF A MINOR
ParentGuardian Full Name
Relationship to Minor
Address

Address

Street Address Line 2

CityStateZip CodeState / Province

Postal / Zip Code
Phone Number
Alternate Number
Minors Full Name
Date of Birth

MonthDayYear
Date
Minors Address if different from above
GradeClass
School
Provider NameFacility
Address

Address of Provider

Street Address Line 2

CityStateZip CodeState / Province

Postal / Zip Code
Date of Appointment s

MonthDayYear
Date
Time
Transportation Details: Purpose: Transportation of the minor/student from school to Valley View Health Centers for health services, consultation, or evaluation.
Health Center Address
Transportation Provider
I, the undersigned parent or legal guardian of the minor named above, hereby give my consent for transportation of the

minor to and from health services as outlined above.

I acknowledge that the transportation is for the purpose of receiving necessary health services and is a crucial part of the minor's treatment plan. I authorize the transportation provider to transport my child for these services, and I agree to hold them harmless for any incident that may occur during the course of the transport, within reason, except in cases of gross negligence or
I understand that I can revoke or modify this consent at any time by providing written notice to the service provider, in

I have been informed of the provider's procedures for ensuring the safety of my child during transport, including the use of a responsible and qualified adult or professional transport provider. I understand that if my child is under the age of 14 and this consent pertains to mental health services, I must provide separate authorization as outlined in Ohio's Mental Health Parental Consent for Treatment provisions. I understand that in the event of an emergency, the transportation provider will contact emergency services (911) and will notify me immediately. I also understand that the provider will inform the health provider of any emergency

I acknowledge that I am responsible for providing accurate and updated contact information to the transportation provider and health provider. I will immediately inform them of any changes.
ParentGuardian Printed Name
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
Witness Printed Name
Witness Signature

Clear
Date

MonthDayYear
Date
For Use of Office Personnel
Transportation Provider Acknowledgment
Transportation Provider Name
Transportation Provider Signature

Clear
Date

MonthDayYear
Date
Valley View
Notice to Patients of Federal Confidentiality Requirements Under 42 CFR Part 2
Patients Name
DOB
Valley View Health Centers provides an array of health care services, including substance use disorder diagnosis, treatment, and referral for treatment. As described in the Center's Notice of Privacy Practices, patient medical records are protected by federal and state laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 ("HIPAA" Certain substance use disorder records are also protected by the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2 The Center's Part 2 unit consists of Medical Providers when providing MAT services and Behavioral Health Providers providing therapeutic services. The above-identified units are the Center's Part 2 Program. Records from the Center's Part 2 Program are protected as described in this Notice. In accordance with 42 CFR 2.22, the following is a written summary of the Part 2 regulations: Generally, a Part 2 Program may only acknowledge that an individual is present or disclose outside the Part 2 Program information identifying a patient as having or having had a substance use disorder in the following instances: The patient's written consent is obtained in accordance with subpart C of Part 2 - An authorizing court order is entered in accordance with subpart E of Part 2 The patient's records are disclosed to medical personnel to the extent necessary to meet a bona fide medical emergency

The disclosure is for the purpose of conducting scientific research (42 CFR 2.52) The disclosure is for the purpose of an audit or evaluation (42 CFR 2.53) Violation of the federal law and regulations to Part 2 is a crime and suspected violations may be reported as follows: To the Health Center Administrator at Valley View Health Centers (740) 947-7726 To the Substance Abuse and Mental Health Services Administration (SAMHSA) office responsible for opioid treatment program oversight at: SAMHSA Opioid Treatment Program Compliance Officer at 866-BUP-CSAT (866-287-2728) or infobuprenorphine@samhsa.hhs.gov If a patient commits a crime on the premises of the Part 2 Program or against personnel of the Part 2 Program, information related to the commission of the crime is not protected. Reports of suspected child abuse and neglect made under state law to appropriate state or local authorities are not protected. After receiving and reviewing this form, we will ask you to acknowledge that you have received it. If you have any questions about this form or its content, please let a member of our staff know.
Printed Patients Name or Legal Guardian*
Relationship to patient*
Patient or Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Valley View

STUDENT INFORMATION & CONSENT FOR SERVICES

Valley View

HEALTH HISTORY

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS?

ADD/ADHD AIDS/HIV

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?

TOBACCO USE

COMPLETE THE SECTION BELOW IF YOU HAVE EVER USED TOBACCO

Valley View

Valley View