SBHC CONSENT Form

School Based Health Center (SBHC) Consent Form

Completion of this form is required for participation in School-Based Health Clinic services and must be renewed at the beginning of each school year.
Please read the agreement below before completing. A parent or guardian must sign a consent form for any student, regardless of age, to receive services at Greater Seacoast Health's School Based Heatlh Center. Greater Seacoast Health complies with all federal and state privacy regulations (HIPAA). Student health information will only be used for treatment and billing purposes.

I understand that I am financially responsible for the services provided to my child.

I authorize the release of my child or student's information regarding the care, services or treatment received to any third-party payers for the purposes of billing.

I understand that my student or child will not receive services at the School Based Health Center unless a consent form is on file, except in an emergency as allowed by the laws of the state of New Hampshire.

I understand that I may withdraw or discontinue the consent given in this form by submitting a request in writing at any time while my child or student is enrolled within the respective district.
My Student/Child is Currently Enrolled at
Indicate which school your student/child attends
Name of Student/Child

First NameLast Name
Student/Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address of Student or Child

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If applicable, please provide the following information on your student or child's primary care provider.
Authorization for the release of visit notes to the student's/child's Primary Care Provider (PCP). Please choose option below.
Select Consent or do not consent to the above statement
Insurance Information (If you do not have insurance, please indicate "Self-Pay" below.
By selecting the services listed below on this form, I authorize and give consent to Greater Seacoast Health's School Based Health Center to provide the following selected services at the Student Based Health Center.
Please select to consent to either Medical Care, Mental Health Care, or both.
Name of Parent/Legal Guardian Completing Form

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number to reach you. Format: (000) 000-0000.
Signature
Date of Consent Completed and Submitted
Should be Empty:

School Based Health Center (SBHC) Consent Form