School Based Health Center Consent Form

Consent to Treat- School Based Health Center

I understand that the School Based Health Center can provide health services to my child. One consent form per child must be signed and file in order for the student to receive services.*
Available services may include physical exams, well child visits, routine lab work, evaluation of injuries, vaccinations, chronic disease management, dental x-rays, dental cleanings, dental sealants, fluoride treatments, behavior assessments, medication management, and individualized therapy. Available services may vary by school district. Services will only be offered as appropriate, if available, and if consent is given. Verbal consent will be obtained PRIOR to each visit.

A. Student Information:

Gender*
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Please mark all that apply to the patient*

Parent/Guardian Information:

**Please list below anyone other than the above named parent or legal guardian who is authorized to bring your child into the clinic for services, or that may give verbal consent to treat. All persons listed below must be 18 or older. This authorization includes examination, necessary blood work, diagnostic imaging, as well as the administration of any recommended immunizations. This authorization will remain in effect unless otherwise notified in writing.
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C. Health Insurance Information:

Medical insurance:
Dental insurance:

D. Student's Health Status:

E. Personal and Family History: (Please check all that apply regarding present and past health history)

Asthma:
Anemia:
Allergies:
Birth Defects:
Behavioral Concerns:
Cancer/Tumor:
Chickenpox:
Diabetes:
Depression:
High Blood Pressure:
Heart Attack/Disease:
Kidney Disease:
Sickle Cell:
Seizures:
Stroke:
Whooping Cough:
Liver Disease:
Skin Conditions:
Stomach Problems:
Mental Illness:
Allergies (including food, pollen, odors, medicines, pets, etc):
Previous Hospitalizations:
Previous Hospitalizations:
*Please note that a Physician's written diagnosis is required for all special medical needs concerning your child, such as a special diet, etc.
Has your child had dental care in the past 12 months?
Does your child have an appointment scheduled at the dental home where dental care is normally provided?
Does your child floss?

COLLABORATIVE CARE DENTAL HYGIENISTS:

Hillary Montgomery, ROH license #1950 Sandlin Rhoads, RDH license #2508 Layne James, ROH license #2385

COLLABORATIVE CARE CONSULTING DENTISTS:

Skylar Garner, DDS license #4185
Consent
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F. Primary Care Provider Referral Agreement

In order for Mainline Health Systems, Inc. to receive reimbursement from Medicaid and certain commercial insurances, a referral from the current PCP is required. However, if a referral cannot be received from the PCP, the parent also has the option to change the student's PCP to Mainline Health Systems, Inc. Mainline will always give referrals in the event the child needs care outside of Mainline Health Systems, Inc.

G. Financial Assistance

In order to determine eligibility for patient assistance programs and for federal reporting necessary to continue funding for this facility, please complete:
Does the student receive free or reduce lunch?*
In an effort to ensure that payment of fees is not a barrier to care, Mainline Health Systems, Inc. offers those who need it a waiver of fees. All waiver requests will be specific to location and services approved, and are granted at Mainline's discretion.

Any services provided but processed by a third party contractor (Lab Corp) such as routine laboratory work must be billed directly.

All patients may apply for Sliding Fee discounts. By signing below, I hereby voluntarily consent to outpatient care encompassing routine diagnostic procedures, examination, and medical treatment, including but not limited to, routine laboratory work (such as blood, urine and other studies), and administration of medications prescribed by the provider. I further consent to dental services (if available and requested), including but not limited to, taking of dental x-rays, routine cleaning, dental sealants, and fluoride treatment. I further consent to behavioral health services (if available and requested), including but not limited to, behavior assessments, medication management, and individualized therapy. I further consent to the performance of those diagnostic procedures, examinations and rendering of treatment by the medical, dental, and/or behavioral health staff, including nurses, dental hygienists, and/or social workers, as is necessary per provider judgment. Regarding release of information: (a) I authorize the clinic to release medical, dental, and/or behavioral health information to the third party insurance carriers for the purposes of filing insurance claims related to my (his/her) care; (b) I further authorize the release of all health information about treatment here to my (his/her) doctor or any designated by me for continuity of care; (c) I further authorize the ability to view prescriptive history from external sources; (d) I further authorize the release of health information to federal and state governing entities for the purposes of required reporting; and (e) I further authorize the exchange of health information to the school as needed for continuity of care and required reporting. I agree that my insurance company, if I have coverage, can be billed for services rendered, and that any remaining co-pays, deductibles, and/or coinsurance may be billed to me directly. I agree that any services provided but processed by a third-party contractor (Lab Corp) such as routine laboratory work (including but not limited to blood, urine, and/or swabs) must be billed to me directly. I further understand that no person is turned away due to inability to pay.
Consent
https://wp02-media.cdn.ihealthspot.com/wp-content/uploads/sites/151/2019/07/24134805/Final-Privacy-Practices-1-2019.pdf
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Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy. * = Input is required
Address

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

* = Input is required