| All fields marked with * are required. |
By completing and signing this form, I consent for the Open Door Family Medical Center School Based Health Center (SBHC) to provide medical care (in person or virtual) to the student named below, including necessary medical tests, evaluations, immunizations and care management, as allowed by New York State law.
I understand that:
- Medical providers employed by Open Door Family Medical Center deliver care in the School Based Health Center (SBHC) located within your child’s school district.
- The School Based Health Centers are licensed by the New York State Department of Health to provide comprehensive primary care services.
- This consent form will remain in effect as long as the student is enrolled in school and lives in the school district, unless I notify the School Based Health Center that I wish to revoke my consent, which I may do at any time.
- All SBHC-enrolled students will have one yearly medical well-visit in the SBHC. When the SBHC provider is the student’s primary care provider, this will be the annual physical exam. For students with a non-SBHC provider as their primary care provider, this will be a brief visit to update the medical record and complete routine screenings.
- Confidentiality between the student and the health provider will be ensured in specific service areas in accordance with the law.
- The student’s health center record will be maintained as a confidential medical record; it is not a school record. 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 Clinical Director, to secure the child’s health and welfare.
- By law, parental consent is not required for prenatal care, sexual education and services, 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.
- Students will be encouraged to involve their parents or guardians in counseling and medical care decisions.
- Parents and guardians are welcome to attend appointments with their children. If a parent or guardian is not accompanying their child, and when needed due to child age or SBHC location in a separate building, patients will be escorted to and from the SBHC by a school or SBHC employee.
I authorize Open Door Family Medical Center to release information regarding treatment to third party payers or others 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. |
| *Student Name: | |
| *Street Address: | |
| *Zip Code: | |
| *Date of Birth: | |
| *Current School: | |
| *Current Grade: | |
| If patient has health insurance, name of insurance company: | |
| *Contact Phone #: | |
| *Other/Emergency Contact Phone #: | |
| *Relationship to Patient: | |
| *Please select one of the following: | |
|
| *Name of Individual Providing Consent: | |
| *Relationship to patient: | |
| *Signature: | 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. |
| *Date: | |