Annual Update to SBHC Registration
If any of the following information has changed in the last year, please complete the following fields
ACKNOWLEDGEMENT AND CONSENT
By signing below, I understand and acknowledge I have read and understand this consent:
I give permission for my child/self to obtain routine health services at the School-Based Health Center.
All insurances will be billed at time of visit. No out-of-pocket costs for medical services rendered in school. No one will be refused services due to the inability to pay.
Annual Wellness Screening visits may be completed for healthy lifestyle assessment. Parents/guardians will be notified before screening visits.
RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION
I authorize the release of any medical or behavioral health information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided.
CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES
I understand and acknowledge that I have read and understand this consent and I have received CFA’s Notice of Privacy Practices currently in effect. I understand that information regarding how CFA will use and disclose my information can be found in CFA’s Notice of Privacy Practices. I understand my consent is effective for as long as CFA maintains my protected health information.
AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION
I give permission to allow Child & Family Agency (CFA) to exchange as needed information with my child’s medical provider, school nurse, and key school personnel in order to effectively care for my child. I understand that SBHC medical and mental health providers may communicate with each other about my child’s care if indicated
I also certify that the health information provided is accurate to the best of my knowledge and understand that incorrect information can be dangerous to the patient’s health. I will notify the School-Based Health Center of any changes to medical information.
By signing above, I understand that this authorization is valid until I revoke this authorization. I understand I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I understand that my child will continue to be enrolled in a CFA SBHC as long as child is enrolled in school that has a CFA SBHC, although yearly updates will be requested. I recognize that health records, if received by the school district, may not be protected by the HIPAA Privacy Rule, but will become education records protected by the Family Education Rights and Privacy Act.