• Registration: School Health Center Information and Consent

  • Shawnee Health is committed to improving the health
    of our area’s students and families.

    To provide health care services for you, Shawnee Health needs some information.

  • Student Date of Birth: *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Does the Student have Insurance?

  • Parent/Guardian Information & Consents

  • School Health Center locations: Your School Health Center consists of a seamless partnership of the School District and Shawnee Health Service, both dedicated to the health and well-being of your child. 

    Murphysboro Wellness can see any student, family member of the student, faculty/staff, and family member of faculty/staff of Murphysboro Community Unit School District #186 . 

    A Medical Provider (Physician, Nurse Practitioner, or Physician’s Assistant), a Dental Provider (Dentist, Dental Hygienist, or Dental Assistant), a Licensed Clinical Social Worker (LCSW) or a Licensed Clinical Professional Counselor (LCPC), a Licensed Dentist, and a Nutritionist are/may be available on site and/or by video visit to provide primary health care, dental care, counseling, and nutritional consultation. We are happy to serve as your primary care provider or on an as-needed basis when your health care provider is not available. To help with continuity of your healthcare, we will send copies of visit notes to your designated health care provider to keep them up to date with your health care needs.

    Services Provided: We offer the same care that you can get at most primary care physician offices. This includes:

    • Routine medical care, examinations, assessments, and screenings including emergency, preventative, acute, and chronic care
    • Routine dental care, examinations, fluoride treatments, and sealants or Dental referrals 
    • Laboratory Testing
    • School and Sports Physicals
    • Immunizations
    • Nutrition Counseling
    • Health education and wellness promotion including, but not limited to smoking cessation, healthy lifestyles, injury prevention, abstinence/sex education, and substance abuse education
    • Suturing of minor lacerations
    • Counseling services
    • Referrals as needed for alcohol, tobacco, and drug and substance abuse counseling
    • When medically indicated, only testing for pregnancy and sexually transmitted diseases including HIV/AIDS will be performed
    • Students who disclose that they are sexually active will receive STD screenings
    • Students who present for Confidential Services, such as performing a urine pregnancy test, will also have the urine sent to the state lab for GC/Chlamydia testing
    • Family Planning services will be provided in the form of appropriate health education which includes abstinence


    Sharing of Information with the School District: We will not share any of your health information with school officials and school officials will not share any of your health information with the School Health Center. However, you may find it convenient if you give us permission to give or exchange records with school officials so that a student’s school required health records are updated and the School Health Center has accurate and complete physicals and immunization information. For example, students entering Kindergarten, 6th grade, and 9th grade must have completed school physicals with updated immunization information before classes can be attended. Students involved in sports must have a sports physical on file to participate in practices or games.

    If you would like for the School Health Center to give or exchange information with the school, please complete the section at the end of this form. You do not have to sign this release. If you do sign the release, the School Health Center will release information until the student leaves the school district or until you revoke or withdraw your permission. To withdraw your permission, you must send a request to: HIPAA Officer, Shawnee Health Service, 109 California Street, P.O. Box 577, Carterville, Illinois 62918-0577

  • Consents

  • If you would like to allow us to release information or exchange records with school officials or allow the school to release information and exchange records with the School Health Center, please check what we can release.*

  • I understand that I may consent to my child being seen at the School Health Center if I am not present or I may require my presence at each visit. Please check the box below to tell us how to handle your child’s visits:

     

    **I understand that I will be contacted by phone before a medical, dental or nutrition care is provided and on a set frequency for behavioral health. 

  • Medical Visits*
  • Medical Telehealth Visits*
  • Counseling Visits*
  • Counseling Telehealth Visits*
  • Dental Visits*
  • Dental Telehealth Visits*
  • Nutrition Visits*
  • Nutrition Telehealth Visits*
  • I voluntarily agree for my child to receive vaccinations and give permission for it to be administered by SH without my physical presence.

  • My child has my consent to receive services offered at the School Health Center. I have been informed of and understand the scope of services which may be provided. I also understand that a parent, legal guardian, or student who is permitted under Illinois law to consent on his or her own behalf, has a right to refuse any health care services.

  • ICARE: Shawnee Health uses the State of Illinois’ ICARE for minor children receiving vaccines to check current immunizations and record immunizations given to the child.
  • Consent to Pay for Service and Treatment: Shawnee Health (SH) participates in Medicare, Medicaid and many insurance plans and will bill your insurers if we have your current insurance information.I agree to the release of any health information needed to process insurance claims for the health care I receive at SH. I agree that insurance payments for these services will go directly to SH. I understand that this agreement may not result in full payment by my insurance for the services I receive and I agree to be responsible to pay for any remaining balances. I understand that if I do not have health insurance coverage, I am responsible for paying all charges for services and treatment by SH. I understand that SH offers a discount to lower income individuals and families. To receive the discount, I understand that I must apply for the program and provide information about my family size and income.
  • Consent to Share Medical Information and RecordsI understand that Shawnee Health (SH) works with other health-related agencies and shares some information with them in order to provide comprehensive care. For a list of Health Information Exchanges (HIEs) that SH uses, please see our Notice of Privacy Practices.

  • Notice of Privacy Practices

    As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Shawnee Health (SH) has our Notice of Privacy Practices available on our website and at the registration desk. This document describes in detail how information about you, the patient, can be used within our office and with others who need to know for the reasons of treatment, payment, health care operations, and as required by law. If we were to disclose your information for any other reason, we would first need your written approval. Your signature below indicates you have received a copy of the Notice of Privacy Practices.

  • Patient Rights and Responsibilities: I reviewed my Rights and Responsibilities as a patient of Shawnee Health. I was given a copy of my Rights and Responsibilities.*

  • By signing below, you voluntarily agree to receive an email containing additional forms and consents that can be completed electronically so that your child can receive services through the School Health Center, as needed.

    I further understand that under Illinois law, minors may have the same capacity as an adult to consent to certain medical and counseling services and no parental or guardian permission is required for such services. Shawnee Health's Consent for Treatment policy defines these services and is available upon request.

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