| All fields marked with * are required. |
| *Office Location: | |
| *Student Name: | |
| *Address: (Street, Apt. #, City) | |
| *State: | |
| *Zip Code: | |
| *Date of Birth: | |
| *Current School: | |
| *Current Grade: | |
I provide consent for my child to receive health care services in the Ossining School District's school based health center. Physicians and Nurse Practitioners employed by Open Door Family Medical Center staff the school based health center program, which is licensed by the New York State Department of Health. Services provided by the school based health center include:
Screenings for vision, hearing, asthma, obesity, scoliosis, Tuberculosis and other medical conditions, first aid, and required and
recommended immunizations by the CDC.
Comprehensive physical examination including those for school, sports, working papers, and school entrance physicals.
Medical care and treatment, including diagnosis of acute and chronic illness and disease.
Mental health screenings and referrals for evaluations.
Medically prescribed laboratory tests.
Education and counseling for the prevention of risk-taking behaviors such as: drugs, alcohol, and smoking, as well as education
on abstinence and prevention of pregnancy, sexually transmitted infections, and HIV, as age appropriate.
Annual health questionnaire/survey.
Referrals for services not provided at the school-based health center.
I understand that confidentiality between the student and the health provider will be ensured in service areas in accordance with the
law, and students will be encouraged to involve their parents/guardians in counseling and medical care decisions.
I give permission for necessary medical tests, evaluations, and management of my child's medical care. As mandated by the Education
Law Article 19 and the Regulations of the Commissioner, health examinations in the school years for which they are required, as well
as those for new entrants and sports physicals, will be shared with the school nurse. Additional health information will be shared with
the school nurse only on a need to know basis, as determined by the SBHC Medical Director to secure the child's health and welfare.
The student's health center record will be maintained as a confidential medical record; it is not a school record. I understand that
confidentiality will be observed between school staff and the students using the SBHC.
I authorize Open Door Family Medical Centers to release information regarding treatment to third party payers or other for purposes
of billing and for any reason that may be required to comply with statutes or regulations in accordance with accepted medical practices.
I have read the above information and have had the opportunity to have any of my questions answered. I understand that this consent
form will remain in effect as long as my child is enrolled in school and lives in the village of Ossining, unless I notify the School Based
Health Center in writing. I understand that I may revoke my consent at any time.
By law, parental consent is not required for prenatal care, services related to sexual behavior, mental health care 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 or legally emancipated. |
| *Signature of Parent or Legal Guardian: | Please sign in the box below using your mouse, touch screen, or touchpad. Clear Use Most Recent SignatureI accept that this is the legal representation of my signature. |
(or student if 18 years or older or
otherwise permitted by law) |
| *Date: | |
| Parent/Guardian Contact Info: |
| Home Phone: | |
| Day Phone: | |
| *Cell Phone: | |
| *Does your child have health insurance? | |
| *Please select one of the following: | |
Please note: if your child's regular doctor is outside of the SBHC, the SBHC will still provide your child with one annual exam to
update the medical record. This will not interfere with your insurance coverage. |