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  • EDWARD R. MURROW HS/2023

    1600 AVENUE L,BROOKLYN,NY 11230
  • PLEASE ANSWER THE QUESTIONS BELOW & THEN SUBMIT (SEND)

    RESPONDA LAS PREGUNTAS A CONTINUACIÓN Y LUEGO ENVÍE (ENVÍE)

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  • IMPORTANT MEDICAL QUESTION

    DOES YOUR CHILD HAVE ANY MEDICAL CONDITION THAT WOULD COMPLICATE ANY SERVICES TO BE PROVIDED? PREGUNTAS MEDICAS LMPORTANTES TIENE SU HIJO(A) A/GUNA CONDICI6N MEDICA QUE PUEDA AFECTAR O COMPLICAR A/GUN SERVICIO QUA SE BRINDE?
    • PARENT | GUARDIAN INFORMATION PADRE | INFORMACIÓN DEL TUTOR 
    • CONTACT INFORMATION FOR PARENT OR GUARDIAN (INFORMACIÓN DE PADRES O GUARDIAN) 
    •  -
    •  -
    • HEALTH INSURANCE INFORMATION

      PLEASE ANSWER THE IMPORTANT MEDICAL RELATED QUESTIONS. SERVICES WILL BE PROVIDED TO YOUR CHILD REGARDLESS OF WHETHER OR NOT YOUR CHILD HAS HEALTH INSURANCE AT NO COST
      ------------------------------------------
      INFORMACION SOBRE EL SEGURO DE SALUD)RESPONDA LAS PREGUNTAS MÉDICAS IMPORTANTES RELACIONADAS. SU HIJO SERA VISTO SIN CARGO Y RECIBIRA LA MISMA EVALUACION Y TRATAMIENTO QUE LOS ESTUDIANTES CON SEGURO.

    • IF YOUR CHILD DOES NOT HAVE INSURANCE CHECK HERE. YOUR CHILD WILL BE SEEN WITHOUT CHARGE AND WILL RECEIVE THE SAME EVALUATION AND TREATMENT AS STUDENTS WITH INSURANCE.
      ___________________________________________

      SI SU HIJOLA NO TIENE CHEQUE DE SEGURO AQUI

      MI HIJO NO TIENE SEGURO SU HIJO SERA VISTO SIN CARGO Y RECIBIRA LA MISMA EVALUACI6N Y TRATAMIENTO QUE LOS ESTUDIANTES CON SEGURO. SI SU HIJOLA NO TIENE CHEQUE DE SEGURO AQUI

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    • PARENTAL CONSENT | CONSENTIMIENTO PATERNO

    • PARENTAL CONSENT FOR SCHOOL-BASED VISION CLINIC SERVICES PLEASE REVIEW YOUR ANSWERS TO MAKE SURE THEY ARE ACCURATE | CONSENTIMIENTO DE LOS PADRES PARA SERVICIOS DE LA CLINICA DE LA VISTA BASADOS EN LA ESCUELA

    • EYEDROPS WILL BE USED TO CHECK FOR ACCURATE EYEGLASS PRESCRIPTION, LAZY EYE, & EYE HEALTH.

      GOTAS PARA LOS OJOS SE UTILIZARA PARA VERIFICAR LA RECETA EXACTA DE LA LENTE, OJO VAGO Y LA SALUD OCULAR.

    • PARENT CONSENT THAT COMPLIES WITH HIPAA TO DISCLOSE HEALTH INFORMATION

      CONSENTIMIENTO DE LOS PADRES QUE CUMPLE CON HIPAA PARA DIVULGAR INFORMACIÓN DE SALUD

      I have read and understand the release of health information on HIPAA COMPLIANCE. My authorization indicates my consent to release vision health information as specified - He leído y entiendo la divulgación de información de salud sobre CUMPLIMIENTO DE HIPAA. Mi autorización indica mi consentimiento para divulgar información de salud visual tal como se especifica

    • PLEASE CHECK TO CONTINUE

      I UNDERSTAND THAT MY CHILD WILL BE RECEIVING COMPREHENSIVE EYE EXAMINATION SERVICES AND MY SIGNATURE PROVIDES CONSENT FOR MY CHILD TO RECEIVE THE SERVICES PROVIDED BY EYES ON KIDS LLC FOR AS LONG AS MY CHILD IS ENROLLED AT SCHOOL. I MAY WITHDRAW MY CONSENT AT ANY TIME WITH WRITTEN NOTICE

      YO ENTIENDO QUE MI HIJO(A) VA RECIBIR UN EXAMEN OCULAR COMPLETO Y MI FIRMA PROPORCIONA CONCENTIMIENTO PARA QUE MI HIJO(A) RECIBA LOS SERVICIOS PRESTADOS PER EYES ON KIDS LLC POR EL LIEMPO QUE MI HIJO(A) ESTE INSCRITO EN LA ESCUELA. PUEDO RETIRAR MI CONSENTIMIENTO EN CUALQUIER MEMENTO MEDIANTE NOLIFICACI6N POR ESCRITO

    • ONLY IF YOU ARE GIVING CONSENT ARE YOU REQUIRED TO ENTER YOUR NAME HERE

      NOTE: BY LAW, PARENTAL CONSENT IS NOT REQUIRED FOR STUDENTS WHO ARE 18 YEARS OR OLDER OR FOR STUDENTS WHO ARE PARENTS OR LEGALLY EMANCIPATED. MY SIGNATURE INDICATES I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES.

      NETA: PER LAY, CONSENLIMIENTO PARENTAL NO ES NECESARIO PARA ESTUDIANTES DE 18 ALIOS O MAYORES O ESTUDIANTES QUA SON PADRES ESTUDIANTES QUE SON EMANCIPADOS LEGALMENTE. MI FIRMA INDICA QUE HE RECIBIDO UNA COPIA DEL AVISO DE PRACTICAS DE PRIVACIDAD.

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