BMRHC School Based Health Center Enrollment Form

SCHOOL BASED HEALTH CENTER ENROLLMENT FORM

Boston Mounain Rural Health Center (BMRHC) is a partner with your school district to offer healthcare services to students. In order for your child to be seen during this school year, this form must be completed for each child and returned to the school or School Based Heath Center (SBHC).

Patient Name

First NameMiddle NameLast Name

Date of Birth:

Date

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School District:

Campus:

Grade:

SBHC Enrollment year

Anticipated Graduation Year:

Please select one:

Previously Enrolled - My child was enrolled in the BMRHC SBHC last year. I approve my child (listed above) to receive health care services at the BMRHC SBHC again for the selected school year and authorize BMRHC to share information confirming my child’s enrollment and participation in the SBHC with designated school personnel as necessary for program reporting, care coordination, and school-related health services. Note: Any forms that have been revised by BMRHC since last signed by parent/guardian will be sent electronically to the parent/guardian for completion. Additional updates may be requested as appropriate.New Enrollee - My child was NOT previously enrolled, but I would like my child to be enrolled into the SBHC for the selected school year to receive health care services and authorize BMRHC to share information confirming my child’s enrollment and participation in the SBHC with designated school personnel as necessary for program reporting, care coordination, and school-related health services. - Note: A staff member from the SBHC will contact you, parent /guardian, to complete the initial enrollment process. Forms can be sent electronically for completion (paper can be requested). IMPORTANT: Even if your child is a patient at a BMRHC clinic, your child has to specifi cally be ‘ENROLLED” into the SBHC to be seen at the SBHC location without your presence (at your discretion).

As the parent/guardian, I grant permission for school personnel (SBHC Coordinator, nurse, or other designated school staff) to transport or walk the above named student to the SBHC (Note: health-related matters, health information cannot be released without consent). Huntsville only- includes transport for x-ray to BMRHC main clinic if needed.:

Please select one:

If Guardian, select relationship:

Parent/Guardian Cell Number:

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Name:

First NameLast Name

Parent/Guardian Signature:

Today's Date:

Date

Electronic Signature Notice

By signing this form electronically, you acknowledge and consent to the secure electronic transmission of your information.

Data Collection and Transmission Notice

All data collected and transmitted through this system is encrypted and handled in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable privacy and security regulations. Your information will be used only for authorized healthcare and administrative purposes and will be protected against unauthorized access.

All data is encrypted in transit, end to end, and at rest. Log data is also encrypted to mitigate the risk of ePHI stored in log files.