SBHC Consent Form

First Name:
Middle Name:
Last Name:
Date of Birth:
Sex:
Male
Female

Address:

City:

County:

State:

ZIP:

Phone:
Contact Preference:
E-mail:
Student School ID #:
Medical Services:
YES, I consent for my child to receive medical care including routine well child exams (includes work, daycare, and sports physicals), appropriate immunizations, and treatment for illness or injury including over the counter and prescription medications and confidential care.
NO, I do not wish for my child to receive medical care at the School Based Health Center (SBHC).
Dental Services:
YES, I consent for my child to receive dental services at the School Based Health Center (SBHC) including preventive care, dental examinations, x-rays, sealants, fillings, local anesthesia, and root canals if necessary. Sealants and other preventable procedures will be provided at school.
NO, I do not wish for my child to receive dental services at the School Based Health Center (SBHC).
By signing this consent, I acknowledge and assert that I am a parent or legal guardian of the student/patient named above. I also acknowledge that I have received a copy of the Notice of Privacy Practices form. As a patient of Ohio Hills Health Centers, I agree to the Patients Rights and Responsibilities as given to me.
I understand that my treating provider(s) have access to my medical records through the CliniSync Health Information Exchange.
If you DO NOT want to have your records shared, please mark the selection below.:
I DO NOT want to have my records shared on a Health Information Exchange. I understand that my test results and medical information will not be accessible to healthcare providers (including emergency room physicians) through CliniSync. I understand that I may choose to participate in CliniSync again at any time.
I hereby authorize Ohio Hills Health Centers and its personnel to deliver routine medical/dental care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of my child. Routine medical and dental care and interventions may include, but not limited to medical evaluation, dental health, physical exam, routine immunizations, injections, x-rays, lab work (examples: throat or nasal swabs, blood draws, wart treatment with liquid nitrogen, minor burns, and minor suturing of lacerations.) I understand that I will be notified of any services my child receives, as well as any abnormal findings and/or further treatment recommendations.

My child's records are protected and can only be accessed by authorized users with restricted access. I also understand I should contact the school nurse or OHHC if I have questions. I understand this consent will remain valid for one year from the date of signature.

Insurance or other health care coverage programs are billed, whenever possible, to help cover the cost of care. I give OHHC the right to submit claims/medical information for reimbursement under any private health insurance policy, Medicare, Medicaid, or any other programs that I identify for which a benefit may be available to pay for services provided to my child through the School Based Health Center.
I have read, understand, and give my consent as outlined above. My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand. If I am the guardian of this student, a copy of my letters of guardianship are attached.
Parent/Legal Guardian's Signature:
Date:
Parent/Legal Guardian's Printed Name:
Patient's Signature (if 18 or older):
Date:
Parent's Printed Name:

* = Required

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