MORA SCHOOL BASED REGISTRATION FORM
SY 2026-2027
Parent/ Guardian Information
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Consent for Services
I consent my child to participate MVCHS School-Based Health Center as follows:
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Yes, I give permission for my child to receive SBHC services; which may include medical, behavioral health, case management and/or dental care and for SBHC staff to access my child’s class schedule (for appointment purposes only) and to ask and receive information from the school nurse about my student’s health history. This includes permission for the SBHC staff to consult with and provide information and records to other health care, mental health providers, dental providers including school health professionals, and for purposes of program evaluation and quality assurance. A copy of the HIPAA Notice of Privacy Practices is available upon request. I have been given a copy of the handout “What You Need to Know about Telehealth” and I understand that some SBHC services may be provided through telehealth.
Decline Services
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No, I DO NOT give permission for my child to receive SBHC services**New Mexico law does not require parental consent for some treatment and services under statues; § 24-1-13.1 NMSA 1978, § 24-1-9 NMSA 1978, § 24-8-5 NMSA 1978, §24-10-2 NMSA 1978, §32A-6A-14, 15 NMSA 1978, §24-7A-6.2 NMSA 1978
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Student Name(s)
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Student Information
Student Name(s)
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Insurance Cards and Account Responsibility
Name of Person Responsible for Account(s)
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Signature of Individual responsible for Account(s)
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Insurance Card(s)
Patient Rights and Responsibilities
Notice of Privacy Practices
Signature
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