Mt. Healthy School-Based Health Center Patient Enrollment

I, the parent/guardian of said student, give consent for my child to receive services at the School-Based Health Center (SBHC) operated by The HealthCare Connection (THCC). I authorize THCC to provide medical, dental, and behavioral health services. Dental treatment includes the application of fluoride varnish to your students’ teeth. Fluoride varnish is an American Dental Association accepted therapy that can reduce dental decay by up to 33%. It is a non-invasive, 20 second treatment. All health care information is confidential. By signing the consent form, I am giving SBHC staff, the school nurse, and my child’s regular medical provider (if applicable) permission to communicate and share medical information regarding my child’s medical condition on an as needed basis with the understanding that this information will continue to be treated in a confidential manner. Confidentiality between the student, parents and SBHC is assured. I do understand by law, some information requires the student’s signed consent prior to disclosure to anyone, including parents & guardians; and that SBHC staff will encourage every student to involve his/her parent/guardian in health care decisions. I also understand that by providing an alternative contact, if I cannot be reached, medical information regarding the above-named child will be shared between the SBHC and the alternative contact. By signing this consent, I understand and agree to the terms and conditions regarding sharing of health information.

I understand there is a charge depending on the service provided and that I will be responsible for payment. When available, my insurance including Medicaid will be billed. The SBHC may release information regarding treatment to third party payers for billing purposes. I understand no student will be denied access to SBHC medical services due to inability to pay.

I understand and agree that my health information may be stored in or released through one or more electronic health records systems through which healthcare professionals and facilities and others involved in my care may view and obtain information. I also understand and agree that, once my health information is released in that way, it may be added into other treating providers’ medical records and be aggregated with the health information of others and used or disclosed to conduct data analysis, or for any other lawful purpose. I understand that this Health Information Release Consent applies to information generated prior to the date of this consent and during any subsequent visit while this consent is in effect. This consent is effective on the date of my signature (or the signature of my authorized representative) below. I may revoke this consent in writing, at any time; provided, however, that such revocation will not apply to any uses or sharing of my heath information that occurred prior to the date the written revocation was received.

I have received a copy of the Notice of Privacy Practices. This Notice describes how my health information may be used or disclosed. I understand that I should read it carefully. Within this Notice of Privacy Practices is contained a complete description of my privacy/confidentiality rights. I am aware that the Notice may be changed at any time. I was given the opportunity to review the Notice and ask questions regarding my privacy rights. I understand that by law, THCC may use or disclose specific information without authorization. Those specific reasons are listed in the Notice. I further understand that my medical information is protected under HIPAA for privacy and confidentiality and cannot be released without my written consent. By signing this form, I am authorizing THCC’s use and disclosure of my protected health information as detailed above. However, I may give notice to restrict the use of such information and revoke my consent in writing.