Lake Hamilton School Packet

School-Based Health Clinic: What to Expect
Providers at HealthStar are working in partnership with your school district to offer you health care services.
What is School Based Health?
HealthStar Physicians has teamed with the Lake Hamilton School District to provide health care to students and staff on campus. With a dedicated clinic located on the school campus, the amount of missed instructional time is greatly decreased. HealtStar will have a provider on campus to see patients from the school during the week.
Can I Choose Not to Participate?
Of course, with this program, you have been offered the option of seeing a HealthStar provider t within your school. It is your choice to use the services.
Things to Remember about Your Appointment:
1.The school nurse needs to be notified of an acute illness or injury

2.The school nurse will triage the situation and contact you for verbal consent prior to beginning the visit.

3.If you have any questions before or after the session, you may ask your school nurse or contact the Wolf Clinic at (501) 463-5447.

4.The New Patient Packet (included here) must be completed prior to initiating your first Telemedicine session. You must complete these forms in order to begin the telemedicine appointment: Telemedicine Consent Form, Patient Information Form, The notice of privacy practices, patient rights, and responsibilities form and the Health Information Exchange (HIE) consent to viewing form.

5.If medications are prescribed by a HealthStar provider, you will be able to pick it up directly at your pharmacy of choice as the HealthStar provider will either phone in or electronically prescribe your medications.

6.If a prescription refill is needed, please call your pharmacy and have them send over a refill request. It will be processed within 1 business day.

7.If you have questions about care or medications, please don’t hesitate to call us at (501) 463-5447.

8.If you have any questions or concerns after reading this form please contact us at (501) 625-7500.

School-Based Health Program
The Lake Hamilton School District is proud to offer quality healthcare services that are easily accessible to the student body through our School-Based Health Program. We want to ensure that our students are healthy so they can get the most out of their educational experience. We expect that students will miss less school because they can be seen early, preventatively, and treated quickly right here on campus.

The NEW SBHC parent consent form is a requirement to use medical services provided through our school campus. This form provides consent for the SBHC provider to offer medical care, preventative and educational services to your student. We strive to keep you informed about everything we are doing.

This is an example of how SBHC services may work. If the school nurse feels your child needs medical services, she will call you. If you want your child to be seen at school and we have the parent consent form on file, then your child will be seen in our SBHC.

If we do not have the necessary forms on file and you want your child to be seen, you can choose to give verbal consent and complete these forms and return within one business day. This may require you coming to the school to complete the forms and establish care processes. We will not provide medical services to your child without having consent from you or another guardian.
If your child is covered under ARKids First and a HealthStar Provider (listed on the next page) is not their assigned Primary Care Provider (PCP), we will need to get a referral from their PCP before each telehealth visit. If you wish to switch your child over to a HealthStar PCP (not required), please complete the PCP Change Form in this packet and return to the School Nurse.
If your child is commercially insured, they may be seen by our provider via telehealth without a referral from their PCP.

If you have any questions, concerns, or feedback, please contact your school nurse or Asa Chapman at (501) 625-7500.

Don’t forget to complete and INITIAL the SBTH parent consent form as it opens the door for any of the

Arkansas law (Ark. Code Ann.§ 20-9-602 (2012) and § 20-16-508 (2012) does not require consent for examination and treatment of STDs, examination and diagnosis of pregnancy, family planning services, substance abuse counseling and treatment, and behavioral health counseling and treatment.

Lake Hamilton School District
Lake Hamilton School District

201 Oakbrook

Pearcy, AR 71964

(501) 463-5447
PARENT CONSENT FORM

THIS FORM MUST BE COMPLETED FOR STUDENTS TO BE SEEN AT THE WOLF CLINIC!
Student Name:
DOB:
Grade:
Address (Street, Apt, City, State, Zip)
Phone #:
Alternate Phone #:
Current primary care physician (PCP):
I understand the following types of services are available through the SBHC Program by the Providers listed below. Please note that YOU WILL BE CONTACTED PRIOR to your child being seen at the clinic for your specific instructions and guidelines.

I give my consent for treatment with prior notification:

Physical/Behavioral Health Services – HealthStar Physicians of Hot Springs. Services to include, initial but are not limited to:

Diagnosis and treatment of acute and chronic illnesses Treatment of minor injuries Health education, counseling, and wellness promotion

Nutrition education and weight management Prescription medications Classroom presentations Referrals for services not provided

Transportation consent - I give my permission for the school to transport my child to any of these services with prior notification to me should the need arise. I understand that my child may be at

greater risk of injury or death by being transported in a private vehicle instead of a school bus and assume such risk on behalf of my child. I agree not to hold Lake Hamilton School District or any of its agents or employees liable for any sum which I/we might claim as a result of injury, or property damage arising out of, or caused by any accident or occurrence during the time said student is being transported.

By signing below, I give my permission for the student listed above to receive treatment through Lake Hamilton School District's School Based Program by the above Providers.
Parent / Guardian Signature

Clear
Date

Month Day Year
Date
*Signed form remains valid while student is enrolled in Lake Hamilton School District or until rescinded in writing.
Locations & Providers
Hamilton West Family Medicine 1629 Airport Road, Suite B Hot Springs, AR 71913 Tel: (501) 767-0075 Fax: (501) 760-2739

Kevin Hale, MD Jodi Sandson, MD Michael Mullins, MD Scott Erwin, MD Jon Robert, MD Pediatrician Courtney Huneycutt, CNP Pediatrics Miranda Edgar, CNP Michelle Auld, CNP Matthew Huskey, CNP Natalie Brown, CNP Gail Pruitt, RNP Amber Cross, LPC

West Gate Family Medicine 2266 Albert Pike Road Hot Springs, AR 71913 Tel: (501) 767-1144 Fax: (501) 767-4455

Amy Reeves, MD Barton Parish, MD Jessica Smith, MD Pediatrician Brittany Lacy, CNP Casey Powell, CNP Monica Brannon, LPC

Fountain Lake Family Medicine 4517 Park Avenue Hot Springs, AR 71901 Tel: (501) 623-7900 Fax: (501) 623-7337

Rick Finch, DO Greg Sketas, MD Alicia Ashley, CNP Julie Dickerson, LPC

Lakeside Family Medicine 124 Hollywood AVE Hot Springs, AR 71901 Tel: (501)624-0070 Fax: (501)624-8721

Ted Faro, DO Jamie Mullenix, MD James Humphreys, MD Julie Dickerson, LPC

Lake Hamilton Family Medicine 1661 Airport Road, Suite F Hot Springs, AR 71913 Tel: (501) 651-4300 Fax: (501) 547-5688

Janette Parchman, MD Hunter Carrington, MD Kayla Stanage, CNP

Glenwood Family Medicine 248 Highway 70 East Glenwood, AR 71943 Tel: (870) 356-4801 Fax: (870) 356-5467

Matthey Hulsey, DO Ellen Moreland, CNS Denise Patten, CNP Shawna Hellums, CNP Pediatrics Priscilla Faulkner, LPC

FirstCare Malvern School-Based 1517 S Main Street Malvern, AR 72104 Tel: (501)332-7525 Fax: (501)467-3071

Larry Brashears, MD Brittany Turner, CNP

FirstCare Walk-In 120 Adcock Road, Suite A Hot Springs, AR 71913 Tel: (501) 651-4500 Fax: (501) 651-4510

Troy Oxner, MD Stephanie Ragsdale, CNP Brent Fikes, CNP Stacy Reynolds, CNP

FirstCare Walk-In Mena 1706 Highway 71 North Mena, AR 71953 Tel: (479) 394-1500 Fax: (479) 394-1525

Kimberly Nance, CNP Anna Davis, CNP

Telemedicine Consent Form
1.I authorize Lake HamiltonSchool to allow me/the patient to participate in school based services or telehealth with HealthStar.

2.The type of services to be provided may include:
- Dia gnosis and treatment of acute and chroni c i llnesses
- Treatment of minor injuries
- Health education, counseling, and wellness promotion
- Prescription medications
- Nutrition education and weight ma nagement
- Cl assroom presentations
- Referrals for services not provided
3.I understand Telehealth service is not the same as a direct patient/healthcare provider visit, because I/the patient will not be in the same room as the healthcare provider performing the service. I understand that parts of my/the patient’s care and treatment which require physical tests or examinations may be conducted by the clinical staff at my/the patient’s location under the direction of the telemedicine healthcare provider.

4.I have received a description of the nature and purpose of the videoconferencing technology and I am informed of expected risks, benefits and complications (from known and unknown causes), attendant discomforts and risks that may arise during the telemedicine session, as well as possible alternatives to the proposed sessions, including visits with a physician in-person. I also understand the risks of not using telemedicine sessions. I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily.

5.I understand that there are potential risks to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my/the patient’s healthcare provider or I can discontinue the telemedicine service if we believe that the environment and/or secure video connections are not adequate for the situation.

6.I understand that the telemedicine session will not be audio or video recorded at any time.

7.I agree to permit my/the patient’s healthcare information to be shared with other individuals (eg School Nurse/Staff) for the purpose of scheduling and billing. I agree to permit individuals (eg School Nurse/Staff) other than my/the patient’s healthcare provider and the remote healthcare provider to be present during my/the patient’s telemedicine service to operate the video equipment. I further understand that I will be informed of their presence during the telemedicine services. I acknowledge that if safety concerns mandate additional persons to be present, then my/guardian permission may not be needed.

8.I acknowledge that I have the right to request the following:
- The omission of specific details of my/the patient’s medical history/physical examination that is personally sensitive, or
- Termination of the service at any time.
9.When the telemedicine service is being used during an emergency, I understand that it is the responsibility of the telemedicine provider to advise my/the patient’s local healthcare provider regarding necessary care and treatment.

10.It is the responsibility of the telemedicine provider to conclude the service upon the termination of the videoconference connection.

11. I/the patient understand(s) that my/the patient’s insurance will be billed by the telemedicine healthcare provider for telemedicine services. A cash price for telemedicine services is available. Please contact our business office for more details at 501-625-7500.

12. My/the patient’s consent to participate in this telemedicine service for the duration of the specific service identified above, or until I revoke my consent in writing.

13. I/the patient agree that there have been no guarantees or assurances made about the results of this service.

14. I confirm that I have read and fully understand both the above and the Telemedicine: What to Expect Form provided. All blank spaces have been completed prior to my signing.

The signature of the patient must be obtained unless the patient is a minor unable to give consent or otherwise lacks capacity.
Name *

Patient First Name Patient Last Name
Patient Date of Birth *

Month Day Year
Date
Parent/Relative/Guardian Name *
Signature *

Clear
Relationship to Patient (If Required)
Today's Date

Month Day Year
Date
Interpreter's Name/Signature (If Required)

Clear
NOTE: THIS DOCUMENT MUST BE MADE PART OF THE PATIENT’S MEDICAL RECORD

To be completed by school nurse:

I hereby certify that I have explained the nature, purpose, benefits, risks of, and alternatives to (including no treatment) the proposed program/procedure, have offered to answer any questions and have fully answered all such questions. I believe that the patient/relative/guardian fully understands what I have explained and
Telemedicine School Nurse Facilitator
Date

Month Day Year
Date

Patient Name:
Date of Birth:

Month Day Year
Date
Weight:
Height:
Previous PCP and Specialists (list any primary care or specialists, such as cardiology, orthopedies, pulmonary, etc):
List all drug and non drug allergies: *
List all current and past medical conditions: *
List any family medical history:
Do you smoke or use smokeless tobacco?

Yes No
How much per day?
Quit date?

Month Day Year
Date
For how long?
Do you drink alcohol?

Yes No
Type of alcohol
Have you ever tested positive for any STD's or communicable disease?

Yes No
If yes, list
How often?
Do you have any history of substance abuse

Yes No
If yes, List
Marital Status:
Any children & how many?
Are you currently employed?
What type of work and where?

Please list any individuals who health related personal information may be released to: *
Print Name (Patient or Patient Representative)
Signature *

Clear
Date

Month Day Year
Date
Relationship to Patient:

My signature below confirms that I have read and understand the payment policy and HIPPA Notice of Privacy Practices.
Signature *

Clear
Should be Empty:

School-Based Health Clinic: What to Expect

What is School Based Health?

Can I Choose Not to Participate?

Things to Remember about Your Appointment:

School-Based Health Program

Lake Hamilton School District

PARENT CONSENT FORM

Locations & Providers

ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM PRIMARY CARE PHYSICIAN SELECTION AND CHANGE FORM

Member Information:

Requested New Doctor (Primary Care Provider):

Telemedicine Consent Form

Social Needs Screening