Student Health Consent Form

Urban Health Plan, (UHP) is a network of community health centers and school-based health centers in the Bronx, Queens and Harlem that provides quality, affordable primary and specialty health care.

At our school-based health centers, your child can receive medical services at no cost to you, regardless of insurance status. Please fill out the consent form to enroll your child.

If you have already completed an Urban Health Plan School Based Health Center Parental Consent form at your previous school, your child is automatically enrolled and can access our services immediately.

School Based Health Center Consent

Step 1 of 6

Emergency Contact

Emergency Contact Name(Required)

First Last

Relationship to Student(Required)

Home Phone(Required)

Cell Phone

Medical Information

Name of Primary Care Doctor

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Last Physical Exam

Dental Information

Name of Dentist

First Last

Phone

Last Dental Visit

Pharmacy Information

Pharmacy Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Health Insurance Information

Does the student have MEDICAID?(Required)

Yes

No

Medicaid #

Sequence #

Does the student have another type of Health Insurance?(Required)

Yes

No

Name of insurance plan

Member ID or Policy Number

Would you like to be contacted by a health insurance enroller?(Required)

Yes

No

What is the best way to contact you?

Parental Consent for Services Received at the School Based Health Center

I have read and understand the services listed which include Dental Services on the next page (School Based Health Center Services). My signature on the yellow line provides consent for my child to receive all services provided by Urban Health Plan, Inc. School-Based Health Center.

I do not want the student to receive Dental services

The student should not recieve Dental services

Signature

I have read and understand the release of health information on the following page. My signature indicates my consent to release medical information as specified in box #2 on the next page.

Signature(Required)

Date(Required)

HIPAA Compliant Parental Consent for Release of Health Information

By law, parental consent is not required for the conduct of mandated screenings, the application of first aid treatment, pre-natal care, services related to sexual behavior and pregnancy prevention, and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students who are 18 years or older, or for students who are parents, married or legally emancipated. My signature indicates that I have received a copy of the Notice of Privacy Practices (last page of packet). My signature also gives my consent to contact other providers who have examined my child.

Signature

Date

SCHOOL BASED HEALTH CENTER SERVICES

I consent for my child to receive health care services provided by the State-licensed health professionals of URBAN HEALTH PLAN, INC. as part of the school health program approved by the New York State Department of Health. I understand that confidentiality between the student and the health provider will be ensured in specific service areas in accordance with the law, and that pupils will be encouraged to involve their parents or guardians in counseling and medical care decisions.
School-Based Health Center services may include, but are not limited to:

Mandated school health services, including: screening for vision (including eye glasses), hearing, asthma, obesity, scoliosis, Tuberculosis and other medical conditions, first aid, and required and recommended immunizations.
Comprehensive physical examination (complete medical examination) including those for school, sports, working papers, and new admissions.
Medically prescribed laboratory tests such as for anemia, sickle cell, and diabetes.
Medical care and treatment, including diagnosis of acute and chronic illness and disease, and dispensing and prescribing of medications.
Mental health services including evaluation, diagnosis, treatment, and referrals.
For Adolescent Students: Reproductive health care services, including abstinence counseling, contraception [dispensing of birth control pills, condoms, Depo (the shot), LARC, among other FDA approved methods] testing for pregnancy, STD screening and treatment, HIV testing, and referrals for abnormal results, as age appropriate and medically indicated.
Health education and counseling for the prevention of risk-taking behaviors such as: drug, alcohol, smoking abuse, education on abstinence and prevention of pregnancy, sexually transmitted infections, and HIV, as age appropriate and medically indicated.
Dental examinations including: diagnosis, treatment, and sealants where available. Please be sure to sign the Red line on the front page if you Do Not want your child to receive DENTAL services at school.
Referrals for service not provided at the school-based health center.
Annual health questionnaire/survey.

NEW YORK CITY DEPARTMENT OF EDUCATION’S FACT SHEET FOR PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION

My signature on first page of this packet authorizes the release of medical information. This information may be protected from disclosure by federal privacy law and state law.
By signing this consent, I am authorizing medical information to be given to the Board of Education of the City of New York (a/k/a New York City Department of Education), either because it is required by law or by Chancellor’s regulation, or because it is necessary to protect the health and safety of the student. Upon my request, the facility or person disclosing this medical information must provide me with a copy of this form. Parents are required by law to provide certain information to the school, like proof of immunization. Failure to provide this information may result in the student being excluded from school.
My questions about this form have been answered. I understand that I do not have to allow release of my child’s medical information, and that I can change my mind at any time and revoke my authorization by writing to the School-Based Health Center. However, after a disclosure has been made, it cannot be revoked retroactively to cover information released prior to the revocation.
I authorize the URBAN HEALTH PLAN, INC. School-Based Health Center to release specific medical information of the student named on the reverse page to the Board of Education of the City of New York (a/k/a New York City Department of Education).
I consent to the release from the School-Based Health Center to the NYC Department of Education and from the NYC Department of Education to the School-Based Health Center, of medical information outlined below in order to meet regulatory requirements and ensure that the school has information needed to protect my child’s health and safety. I understand that this information will remain confidential in accordance with Federal and State law and Chancellor’s Regulations on confidentiality:
Information Required by Law or Chancellor’s Regulation including but not limited to:

Comprehensive Physical Exam (Form CH-205 or equivalent sports exams, etc.)
Vision and hearing screening results
Immunizations (required /recommended)
Tuberculin Test Results

Information to Protect Health and Safety:

Conditions which may require emergency medical treatment including chronic illness
Conditions which limit a student’s daily activity
Diagnosis of certain communicable diseases (not including HIV infection/STI and other confidential services protected by law).
Health insurance coverage
Enrollment in School-Based Health Center
Individualized Education Program (IEP)

Time Period During Which Release of Information is Authorized: From: Date that form is signed on opposite page
To: Date that student is no longer enrolled in the SBHC

Note: This school Based Health Center Parental Consent Form has been approved by DOE/OSH

HIPAA Release of Medical Information

Dear Parent/Guardian:

In order to better coordinate the care provided to your child, we are required to inform your child’s doctor that his/her patient is enrolled in the School Based Health Center (SBHC). Signing this form will allow us to better coordinate comprehensive medical care with his/ her physician. It does not change your medical insurance plan and it does not change your child’s doctor. Please complete the following information.

I authorize

Doctor's Name(Required)

First Last

to release any medical information including but not limited to current treatment plans and most recent Physical Exam about

Student's Name(Required)

First Last

Date of Birth(Required)

to the Urban Health Plan, Inc. SchoolBasedHealthCenter.

As the parent, I understand that I have the right to revoke this authorization at any time by writing to the health care provider listed below. I may revoke this authorization except to the extent that action has already been taken based on this authorization.

Parent/Legal Guardian Signature(Required)

Date(Required)

Student Health Consent Form

School Based Health Center Consent

Student Information

Parent/Legal Guardian Information

Emergency Contact

Medical Information

Dental Information

Pharmacy Information

Health Insurance Information

Parental Consent for Services Received at the School Based Health Center

HIPAA Compliant Parental Consent for Release of Health Information

SCHOOL BASED HEALTH CENTER SERVICES

NEW YORK CITY DEPARTMENT OF EDUCATION’S FACT SHEET FOR PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION

Child's Medical History

Child's Social History

Do you have any concerns about any of the following?

Family Medical History

Does anyone in the family have any of the following medical conditions?

Family Beliefs

School Based Health Clinic Billing Policy

HIPAA Release of Medical Information

Dear Parent/Guardian: