I understand that my signature gives consent for the CCHS School Based Health/Dental Center Providers to treat my child and to communicate with my child’s primary health care provider. I give CCHS permission to call my home, leave a message regarding healthcare information. CCHS may also mail healthcare information to my home.
I understand that my child’s health information will be used for treatment, payment and health care operations.
I recognize that school directories will be used to obtain information left blank on the enrollment form.
My child’s immunization record may be shared between the School Nurse and the School Based Health/Dental Centers. For the purposes of care coordination and case management, School Clinical Staff will have access to the SBHC/SBDP health records and School Clinical Staff shall share health information with the SBHC/SBDP staff. School Clinical Staff are required to treat the information in the SBHC/SBDP health record as confidential and comply with the HIPAA Privacy Rule and the FERPA Act.
I understand the student may request that visits remain confidential. Maryland Law does not require parental consent for treatment or advice about drug abuse, alcoholism, sexually transmitted diseases, pregnancy, or contraception. Students age 12 and over may receive behavioral health services without parental consent. Under no circumstances, do SBHC/SBDP records become part of the student’s school health record.
I understand that services provided to my child will be billed to my insurance carrier or Medical Assistance. I may receive a bill from CCHS for copays and/or deductibles.
I understand that my signature indicates that I have had the opportunity to receive and review the Choptank Community Health’s Notice of Privacy Practices. If I do not have insurance, visit costs will be billed for the full cost of services or at a reduced rate with a sliding fee discount, if applicable. I will be offered a Sliding Fee Application whether or not I have health/dental insurance.