SVLSD-Intake-Form2026

Valley View Health Centers
School-Based Health Services Enrollment Packet
Welcome to Valley View Health Centers School-Based Health Center (SBHC)
Our school-based health center offers students, staff, and community members year-round access to medical care when it might otherwise not be available. The 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 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 health information documents are received, we will be able to begin scheduling your child for appointments. A VVHC staff member will reach out to the parent or legal guardian to complete remaining required paperwork for service.
You may complete the other required documents via:
Please feel free to contact us during regular business hours at 740-289-1638 if you have any questions.
STUDENT INFORMATION & CONSENT FOR SERVICES
Today's Date:

MonthDayYear
Date
Student's Name:

First NameMiddle InitialLast Name
Student's Date of Birth:

MonthDayYear
Date
Student's Current School:
Student's Current Building:
Student's Current Grade:
Parent or Legal Guardian
Parent or Legal Guard Information Must Be Provided if Patient is Under 18
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone
Format: (000) 000-0000.
Relationship to Patient

Rows	Primary Insurance	Secondary Insurance
Insurance Company Name
Policy Identification Number
Policy Holder Name
Policy Holder Date of Birth

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 WHC and Scioto Valley Local Schools to share/release/exchange information with school nurses, school counselors, school social workers and/or school administrators about 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. WHC 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 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 WHC. I understand that I am not required to sign this authorization form and the WHC 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.
Student's Name:
Parent/Guardian Printed Name:
Parent Guardian Signature:
Date:

MonthDayYear
Date
(If student 18+) Student Signature:
Date:

MonthDayYear
Date
COMMUNITY
ACTION
COMMITTEE
OF PIKE COUNTY
SBHC Rev. 4/2026

Valley View
HEALTH CENTERS
Sliding Fee Discount Information
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

Rows	Employed Person	Company Name	Income Before Taxes	Paid How Often
1
2
3
4
5
6

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:
Date:

MonthDayYear
Date
OR
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:
Date:

MonthDayYear
Date

Telehealth Informed Consent
Patient Name:
Date of Birth:
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.
By signing below, I agree and understand:
Telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.
I may opt out of the telehealth visit at any time. This will not change my ability to receive future care at this office.
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.
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.
Information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care.
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 records).
I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.
The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.
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.
SBHC Rev. 4/2026

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.
Electronic communications cannot be used for emergencies or time-sensitive matters.
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.
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, etc.).
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.
The inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.
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.
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 can reach the National Suicide Hotline by calling or texting 988.
Parent/Guardian Signature (if 18+ student signature):
Date:

MonthDayYear
Date
Relationship to Patient:
Office Use:
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:
Date:

MonthDayYear
Date
SBHC Rev. 4/2026

PARENTAL CONSENT FOR TRANSPORTATION OF A MINOR
Parent/Guardian Information:
Parent/Guardian Full Name:

First NameLast Name
Relationship to Minor:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Alternate Number:
Format: (000) 000-0000.
Minor Information:
Minor's Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Minor's Address (if different from above):
Grade/Class:
School:
Health Provider Information:
Provider Name/Facility:
Address of Provider:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Appointment (s):

MonthDayYear
Date
Time:

Hour Minutes

AM/PM Option
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:
Consent Statement:
I, the undersigned parent or legal guardian of the minor named above, hereby give my consent for transportation of the minor to and from the behavioral 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 willful misconduct.
SBHC Rev. 4/2026

I understand that I can revoke or modify this consent at any time by providing written notice to the service provider, in accordance with Ohio law.
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 situations.
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.
Parent/Guardian Printed Name:
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Witness Printed Name:
Witness Signature:
Date:

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

MonthDayYear
Date
SBHC Rev. 4/2026

Valley View
HEALTH CENTERS
Notice to Patients of Federal Confidentiality Requirements Under 42 CFR Part 2
Patient's Name:
DOB:

MonthDayYear
Date
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 (42 CFR 2.51)
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 Patient's Name or Legal Guardian:
Relationship to patient:
Patient or Legal Guardian Signature:
Date:

MonthDayYear
Date
SBHC Rev. 4/2026

CONSENT TO DISCUSS MEDICAL INFORMATION
Student Information:
Student Name:
Date of Birth:

MonthDayYear
Date
School:
Parent/Legal Guardian Information:
Name:
Phone Number:
Format: (000) 000-0000.
Purpose of This Authorization
This form gives permission to Valley View Health Centers to discuss your child's medical information with the individuals
you list below.
Authorized Individuals
I authorize the Valley View Health Center to verbally discuss my child's health information with the following
individual(s):

I authorize the Valley View Health Center to verbally discuss my child's health information with the following individual(s):

Rows	Name	Relationship to Child	Phone Number
1
2
3
4

Information That May Be Shared(Initial all that apply)
Restrictions (Optional)
List any limits on what may be shared or with whom:
SBHC Rev. 4/2026

Important Information
- This authorization is voluntary and will not affect your child's ability to receive care.
- This authorization allows discussion only and does not permit the individuals listed above to make medical decisions for your child.
- You may revoke this authorization at any time by submitting a written request to Valley View Health Centers.
- This authorization applies only to verbal communication unless otherwise required or permitted by law.
Ohio-Specific Notice
- Under Ohio law, certain health services (such as behavioral health, substance use treatment, and reproductive health services) may be protected by additional confidentiality rules. In some cases, minors may consent to their own care, and related information may not be shared without the minor's permission, even if this form is signed.
- Valley View Health Centers will follow all applicable federal and Ohio laws, including HIPAA and Ohio minor consent laws, when determining what information may be disclosed.
Expiration of Authorization
This authorization will remain in effect for one year from the date of the signature on this form.
Signature
I have read and understand this authorization. I give permission for the School-Based Health Center to discuss my child's medical information as indicated above.
Parent/Legal Guardian Signature:
Printed Name:
Date:

MonthDayYear
Date
SBHC Rev. 4/2026

Valley View
HEALTH CENTERS
As a Federally Qualified Health Center (FQHC), our School-Based Health Center (SBHC) is designed to bring high-quality, accessible, and comprehensive health care services directly to students where they spend the majority of their time-at school. Our goal is to improve the physical, emotional, and social well-being of children and adolescents by reducing barriers to care, supporting academic success, and fostering healthier communities.
Mission - To provide access to affordable, high-quality, integrated health care for all.
How the School-Based Health Center (SBHC) works:
- You must complete the attached consent form and other information pages and return them to the school.
- You or your child may schedule an appointment in the SBHC if your child is sick or injured. You can also schedule an appointment for physicals, immunizations, required sports or employment physicals, dental care, vision screenings, and all associated health care concerns. Any necessary prescriptions will be provided.
- After your child's visit with the provider, attempts will be made to contact you as necessary.
Services Offered
Our SBHC offers a full range of integrated services, consistent with the scope of a full-service FQHC, including:
Primary Care Services:
- Well-child exams and sports physicals
- Diagnosis and treatment of acute and chronic conditions
- Immunizations
- Health Screenings (vision, hearing, BMI, etc.)
- Health education and preventive counseling
Behavioral Health Services:
- Individual and group therapy
- Crisis intervention
- Substance use screening and counseling
Dental Services (at select locations):
- X-Rays
- Preventive care (cleanings, sealants, fluoride treatments)
- Screenings
- Basic restorative care & simple extractions
Reproductive and Sexual Health:
- STI testing and treatment
- Family planning and contraceptive counseling
- Pregnancy testing and referrals
Care Coordination & Support Services:
- Case management and referrals
- Health insurance enrollment support
SBHC Rev. 4/2026

- Linkage to social services and specialty care
Staffing
SBHCs are staffed by a multidisciplinary team which may include:
- Licensed medical providers (MDs, DOs, NPs, PAs)
- Licensed clinical social workers (LCSWs)
- Dental hygienists and dentists
- Medical assistants and care coordinators
- Health educators/case managers
Access and Confidentiality
Services are available to all students regardless of insurance status or ability to pay. We offer sliding fee discounts based on income and family size. Parental consent is obtained for minors as required by state law, and all services are provided in a confidential and culturally competent manner.
Partnership with Schools
Our SBHCs are operated in close partnership with the school district to ensure services are aligned with school schedules, policies, and student needs. Together, we aim to reduce absenteeism, improve academic performance, and support the overall well-being of the student population.
Notice of Privacy Practices Patient Rights and Responsibilities
Patient Rights
- To be treated with respect, dignity, and compassion.
- To get care that is free of discrimination on the basis of age, sex, race, faith, religion, marital status, national origin, disability, genetic information, color, gender identity, sexual orientation, public assistance status or criminal record, or any other protected class.
- To get care based on your own needs. VVHC makes language interpretation services available at no cost to you.
- To have your privacy protected at all levels of care, including chin-in and in treatment areas. WHC assures the privacy and security of your records and can share information about you only with your permission, when medically necessary, or as otherwise permitted by law.
- To have access to your own health records.
- To be given the names of the doctors providing your and the names and titles of other healthcare staff who assist you.
- To be given information about your diagnosis, prognosis, and recommend treatment in ways that you can understand so you can make informed decisions about your care.
- To have continuity of care within the laws and policies that apply to the clinic and within resources available.
- To have information about how to get after hours or emergency care.
- To refuse a medication, treatment or procedure to the extent permitted by law, and be informed of the possible health consequences of your refusal.
- To get a consult or change your doctor, dentist, or healthcare provider.
- To be informed on Advanced Directives and Living Wills.
- To be informed of fees for services and/or changes in fees.
Patient Responsibilities
- To provide truthful and complete information about your current health complaint, past medical history, and other information about your health.
- To let us know that you understand your diagnosis, treatment plan, medicines, and what is expected of you. Ask questions when you don't understand.
- To follow the treatment plan set by your healthcare team and participate in your care.
- To keep your scheduled appointments and let us know when you can't keep an appointment.
SBHC Rev. 4/2026

- To assist us with billing and/or payments issued to help with the processing of third-party payments, and accept responsibility for any fees not covered by insurance.
- To treat other patients and the healthcare providers and staff of WHC with respect.
- To respect the property and facilities of VVHC.
- To arrange appropriate transportation and support at home after procedures requiring sedation or anesthesia or as indicated on discharge instructions.
THE FOLLOWING IS A SUMMARY OF WHEN AND WHY YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:
To Provide Treatment
VVHC may use your health information to coordinate or manage your care within VVHC and with other individuals outside of WHC involved in your care, such as other health care professionals. For example, certain service providers involved in your care need information about your medical condition in order to deliver appropriate services. Health care providers include physicians, hospitals, and other health caregivers who provide services to you.
To Obtain Payment
WHC may use and share your PHI so that we are paid for the cost of your care. We may bill and share PHI with other providers, an insurance company, you, or a third party. For example, we may need to give your health plan PHI about care you have received at VVHC so your health plan will pay us or reimburse you for the care. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your health plan will cover the treatment. We may share your PHI to facilitate payment to another provider who has participated in your care.
To Conduct Health Care Operations
WHC may use and disclose health information for its own operations and as necessary to provide quality care to all of VVHC's service recipients. Health care operations include such activities as:
- Quality assessment and improvement activities.
- Activities designed to improve health or reduce health care costs.
- Protocol development, case management and care coordination.
- Contacting health care providers and consumers with information about treatment alternatives and other related functions that do not include treatment.
- Professional review and performance evaluation.
- Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs
- Business planning and development including cost management and planning related analyses and formulary development
- Business management and general administrative activities of VVHC
As an example, VVHC may use your health information to evaluate its staff performance, or combine your health with other VVHC consumers in evaluating how to more effectively serve all VVHC consumers. Your health information may be disclosed to VVHC staff and contracted personnel for training purposes, or used to contact you as a reminder regarding a visit to your, or to contact you as part of a community information mailings (unless you tell us you do not want to be contacted). We may combine the PHI we have with the PHI from other health systems to see where we can make improvements in the care and services we offer. When we share PHI with other health systems for this type of comparison, we remove information that identifies you so others may study healthcare and healthcare delivery without learning who you are.
For Appointment Reminders
VVHC may use and disclose your health information to contact you as a reminder that you have an appointment. If you do not wish to receive appointment reminders or wish to be contacted at a certain telephone number, then be sure to tell the representative who is registering your for services.
For Treatment Alternatives
VVHC may use and disclose your health information to tell you about or recommend possible service options or alternatives that may be of interest to you.
THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES WHEN OUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED:
Individuals Involved in Your Care or Payment for Your Care
We may release the PHI about you to a family member or other designated person who is involved in your medical care. We may also give PHI to persons responsible for your care where you are and of your condition. In addition, we may share PHI
SBHC Rev. 4/2026

about you to an agency assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
To Avert a Serious Threat to Health or Safety
We may use and share PHI about you when necessary to prevent a serious threat to:
- Your health and safety;
- The public's health and safety; or
- Another person's health and safety.
When Legally Required
VVHC will use and disclose your health information when it is required to do so by any federal, state or local law and is limited to the relevant requirements of each law.
When There Are Risks to Public Health
VVHC may disclose your health information for public activities and purposes in order to:
- Prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions;
- Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease;
- Under the Federal Drug Administration's jurisdiction for purposes related to the quality, safety, or effectiveness of a regulated product or activity.
To Report Abuse, Neglect or Domestic Violence
VVHC is allowed to notify government authorities if VVHC believes a patient is the victim of abuse, neglect or domestic violence. VVHC will disclose this only when specifically required or authorized by law or when the patient agrees to the disclosure.
To Conduct Health Oversight Activities
VVHC may disclose your health information to a health oversight agency for activities including audits, civil administrative or criminal investigations, inspections, licensure or disciplinary action. WHC, however, may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.
In Connection with Judicial and Administrative Proceedings
VVHC may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when VVHC makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information. [Some States require a court order for the release of any confidential medical information and may be more protective than the Federal requirements.]
For Law Enforcement Purposes
As permitted or required by State law, WHC may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:
- As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process.
- For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
- Under certain limited circumstances, when you are the victim of a crime.
- To a law enforcement official if VVHC has suspicion that your death was the result of criminal conduct including criminal conduct at WHC.
- In an emergency in order to report a crime.
For Research Purposes
VVHC may, under very select circumstances, use your health information for research provided that certain requirements are satisfied, including:
- Approval by an "Institutional Review Board" under federal regulations or by a privacy board that meets the requirements of HIPAA and
- Representations by the researcher that the PHI is necessary for the research.
To a Coroner or Medical Examiner or Funeral Director
VVHC may disclose your PHI to a coroner or medical examiner for purposes of identifying a deceased person, determining a cause of death, or other duties authorized by law. VVHC may disclose you PHI to a funeral director, consistent with applicable law, as necessary for the funeral director to carry out his or her duties. Such information may be provided in reasonable anticipation of your death.
SBHC Rev. 4/2026

For Organ, Eye or Tissue Donation Purposes
VVHC may use or disclose your PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitations organ, eye or tissue donation transplantation.
In the Event of a Serious Threat to Health or Safety
VVHC may, consistent with applicable law and ethical standards of conduct, disclose your health information if VVHC, in good faith believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or the health and safety of the public.
Disaster-Relief Efforts
We may disclose medical information about you to an organization assisting in a disaster-relief effort so that your family can be notified about your condition, status, and location.
For Specified Government Functions
In certain circumstances, the Federal regulations authorize VVHC to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.
For Worker's Compensation
VVHC may release your health information to comply with laws relating to worker's compensation or similar programs established by law, that provide benefits for work-related injuries or illnesses without regard to fault.
Health Information Exchange (HIE)
We may participate in an electronic Health Information Exchange ("HIE") to facilitate the sharing of your medical information for treatment purposes. The HIE is a network in which providers, such as doctors and other health care providers, participate to exchange patient information in order to facilitate health care. There are many circumstances when it is beneficial for a VVHC health care provider to have timely access to patient medical records to coordinate care. For example, if you were recently admitted to the hospital and was being seen by VVHC then it would be ideal the provider to know medications you are currently taking, so they can avoid any harmful drug interactions. Please see Ohio Rev. Code § 3798.06 information regarding your rights to opt out of sharing your medical information via an HIE or access the form by going to https://clinisync.org/wp-content/uploads/2020/11/Request-to-Change-Consent.pdf
Uses of Medial Information Requiring Authorization
Psychotherapy Notes
We must obtain your written permission to disclose psychotherapy notes except in certain circumstances. For example, written permission is not required for use of those notes by the author of the notes with respect to your treatment or use or disclosure by us for training of mental health practitioners, or to defend VVHC in a legal action brought by you.
Marketing
We must obtain your written permission to use or disclose your medical information for marketing purposes except in certain circumstances. For example, written permission is not required for face-to-face encounters involving marketing, or where we are providing a gift of nominal value (example: a coffee mug), or a communication about our own services or products (example: we may send you a postcard announcing the arrival of a new doctor or service being offered).
Sale of Medical Information
We must obtain your written permission to disclose your medical information in exchange for remuneration.
Other Uses and Disclosures
Other Uses and Disclosures of your medical information not covered by the categories included in the Notice or applicable laws, rules or regulations will be made only with written permission, then you may revoke it at any time. We are not able to take back any Uses or Disclosures that we already made with your authorization. We are required to retain your medical information regarding the care and treatment that we provided to you.
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
Other than stated in the Notice VVHC will not disclose your health information without your written authorization. Uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosure that constitutes a sale of protected health information
SBHC Rev. 4/2026

require your written authorization. If you or your representative authorities VVHC to use or disclose your health information, you may revoke that authorization in writing at any time. If you revoke your permission, then we will no longer use or share PHI about you for the reasons covered by your written permission, except to the extent that we have already used or shared your PHI.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
The physical form of your PHI and billing records is our business record and is the property of WHC. The PHI contained in those records is your PHI. You have the following rights regarding your PHI that VVHC maintains:
Rights to request restrictions
You may request restrictions on certain uses and disclosures of your health information. However, WHC is not required to agree to your request. If we agree to your request, then we will fulfill your request unless the PHI is needed to provide emergency treatment to you. You must make your request for any restrictions or limitations in writing to the Privacy Officer where you received services. In your request, you must tell us:
- what PHI you want to limit;
- whether you want to limit our use, disclosure, or both; and
- to whom you want the limits to apply (for example, disclosures to your spouse).
VVHC will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.
Right to Inspect and Copy Your Health Information
Unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see you PHI upon your request. Usually, this PHI includes information we use to make decisions about your care and billing records, but does not include:
- psychotherapy notes;
- information compiled for use in or created in anticipation of a civil, criminal, or administrative action or proceeding;
- certain lab results subject to the Clinical Laboratories Improvement Act of 1988; or
- other types of information we did not use to make decisions about your health care.
A request to inspect and copy records containing your health information may be made in writing to the Office Manager where you received services. If you request a copy of your health information, VVHC may charge a reasonable fee for copying and assembling records associated with your request. You may also request a copy of your electronic health records in electronic format. Your request will be reasonably accommodated and WHC may charge a reasonable fee associated with your request.
Right to Amend Health Care Information
You or your representative has the right to request that VVHC amend your records if you believe that your health information is incorrect or incomplete. That request may be made as long as the information is maintained by VVHC. A request for an amendment of records must be made in writing to the Privacy Officer 941 Market St, Piketon, OH 45661, (740) 289-2371. WHC may deny the request if it is not in writing or does not include a reason for the amendment. The request also may be denied if your health information records were not created by WHC, if the records you are requesting are not part of VVHC's records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in the opinion of, WHC the records containing your health information are accurate and complete.
Right to Appeal a Denial of Access to Protected Health Information
You have the right to access your PHI. There are some limitations to that right. Your health provider may decide for clear treatment reasons that sharing your PHI with you will likely have an adverse effect on you. If this happens, then you may choose a different health provider. We will then provide your PHI to the health provider you choose.
Right to know what disclosure have been made
You have the right to request an "accounting of disclosures" of your health information made by VVHC or our Business Associates. This is the list of PHI we have made for certain reasons described in the Notice of Privacy Practices, including reasons related to public healthcare operations. When we make these disclosures, we are not required to obtain your authorization before we share your PHI with others. The request for an accounting must be made in writing to the Privacy Officer at 941 Market Street, Piketon OH, 45661. The request should specify the time period for excess of (6) six years. WHC would provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee. We will tell you about any cost involved. You may choose to withdraw or modify your request before any costs are incurred.
Right to request confidential communication
SBHC Rev. 4/2026

You have the right to request that we communicate with you about PHI in a certain way or at a certain location. For example, you may ask that we only contact you at work or by mail. You must make your request for confidential communications in writing to the Office Manager where you received services. We will not ask you the reason for your request. We will agree to all reasonable requests. Your request must specify how or where you wish to be contacted. For Example, if you wish to be contacted by telephone, then be sure provide an appropriate telephone number.
Right to a paper copy of this notice
You or your representative has a right to a separate paper copy of this Notice at any time even if your or your representative has received this Notice previously. To obtain a separate paper copy, please contact the Valley View Health Center where you received services or the Privacy Officer at (740)289-2371.
Right to Restrict Release of Information for Certain Services
You have the right to restrict the disclosure of your information to your health plan regarding services for which you have paid out of pocket in full. This information can be released only upon your written authorization.
Right to Breach Notification
You have the right to be notified in the event that VVHC (or one of our Business Associates) discover a breach of unsecured PHI. WHC will notify you of such breach in accordance with federal requirements.
DUTIES OF VALLEY VIEW HEALTH CENTER (VVHC)
The agency is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. VVHC is required to abide by the terms of this Notice as may be amended from time to time. VVHC reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If WHC changes its Notice, WHC will provide a copy of the revised Notice to your or your appointed representatives.
WHERE TO FILE A COMPLAINT
You or your personal representative has the right to express complaints to VVHC and to the Secretary of DHHS if your or your representative believes that your privacy right have been violated. Any complaints to VVHC should be made in writing to the Privacy Office at 941 Market Street, Piketon, OH 45661. VVHC encourages you to express any concern you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington D.C., 20201 or call 1-877-696-6775.
CONTACT PERSON
VVHC has designated a contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact this person at 941 Market Street, Piketon OH, 45661 or at (740) 289-2371.
Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:
Privacy Officer
941 Market Street
Piketon, OH 45661
(740) 289-2371
Notice: If you send health information to WHC via email, please know that your message may be sent in an unencrypted email. An unencrypted email means that there is a risk that the information in the email and any attachments could potentially be read by a third party when it is sent through the internet.
Eff: 4/11/2003; Rev: 9/17/2013, 3/1/2024
SBHC Rev. 4/2026
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Valley View Health Centers

School-Based Health Services Enrollment Packet

Welcome to Valley View Health Centers School-Based Health Center (SBHC)

STUDENT INFORMATION & CONSENT FOR SERVICES

Parent or Legal Guardian

Health Information

Student/Patient Information

Household Member Information

Valley View

Sliding Fee Discount Information

Sliding Fee Scale

Telehealth Informed Consent

By signing below, I agree and understand:

Office Use:

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

TOBACCO USE

COMPLETE THE SECTION BELOW IF YOU HAVE EVER USED TOBACCO

Consent for Vaccinations

PARENTAL CONSENT FOR TRANSPORTATION OF A MINOR

Parent/Guardian Information:

Minor Information:

Health Provider Information:

Transportation Details:

Consent Statement:

For Use of Office Personnel:

CONSENT TO DISCUSS MEDICAL INFORMATION

Student Information:

Parent/Legal Guardian Information:

Purpose of This Authorization

Authorized Individuals

Restrictions (Optional)

Important Information

Ohio-Specific Notice

Expiration of Authorization

Signature

Valley View

Staffing

Access and Confidentiality

Partnership with Schools

Notice of Privacy Practices Patient Rights and Responsibilities

Patient Rights

Patient Responsibilities

THE FOLLOWING IS A SUMMARY OF WHEN AND WHY YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED:

To Provide Treatment

To Obtain Payment

To Conduct Health Care Operations

For Appointment Reminders

For Treatment Alternatives

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES WHEN OUR HEALTH INFORMATION MAY ALSO BE USED AND DISCLOSED:

Individuals Involved in Your Care or Payment for Your Care

To Avert a Serious Threat to Health or Safety

When Legally Required

When There Are Risks to Public Health

To Report Abuse, Neglect or Domestic Violence

To Conduct Health Oversight Activities

In Connection with Judicial and Administrative Proceedings

For Law Enforcement Purposes

For Research Purposes

To a Coroner or Medical Examiner or Funeral Director

For Organ, Eye or Tissue Donation Purposes

In the Event of a Serious Threat to Health or Safety

Disaster-Relief Efforts

For Specified Government Functions

For Worker's Compensation

Health Information Exchange (HIE)

Uses of Medial Information Requiring Authorization

Psychotherapy Notes

Marketing

Sale of Medical Information

Other Uses and Disclosures

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

Rights to request restrictions

Right to Inspect and Copy Your Health Information

Right to Amend Health Care Information

Right to Appeal a Denial of Access to Protected Health Information

Right to know what disclosure have been made

Right to request confidential communication

Right to a paper copy of this notice

Right to Restrict Release of Information for Certain Services