DISTRICT 207 SCHOOL-BASED HEALTH CENTER PARENTALGUARDIAN CONSENT FORM FOR HEALTH SERVICES

DISTRICT 207 SCHOOL-BASED HEALTH CENTER PARENTALGUARDIAN CONSENT FORM FOR HEALTH SERVICES

Please complete this form and read, initial and sign for consent.
Name

First NameLast Name
Which School do you attend?
School ID# (if applicable)
Grade entering
Legal Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Ethnicity
Name of Parent/Guardian:

First NameLast Name
Parent/Guardian's Phone number
Please enter a valid phone number.
Parent's Email Address:
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.
Student's Doctor/Health Care Provider:
Allergies to Medication?
Do you have insurance coverage for medical services?

Yes, Private InsuranceYes, State Insurance (Medicaid)No, no insurance
Type of insurance, Recipient/Member ID and Group Number:
The above-named student has my consent to receive services offered by the School-Based Health Center and its contracted providers located in Maine East High School and/or Maine West High School. I have received a list of the services available at the School-Based Health Center and understand and consent to the scope of services that the student may receive. I understand that a parent, legal guardian, or student who is permitted under Illinois law to consent on his or her own behalf has the right to refuse any health care services. I further understand that the services available through the School-Based Health Center are not intended as primary care, and are not a substitute for parental monitoring of the student's health or regular visits to a primary care physician.

Students must have a signed parental/guardian consent from on file before they can receive most services at the SBHC.

Illinois Consent and Confidentiality laws allow minors over age of 12 the same capacity as an adult to consent to certain health services and no parental permission is required for such services. I also understand that if my child is 12 or older and were to receive mental health/substance abuse services at the school based health center, he/she may receive up to eight therapy sessions without my consent. By law, a child under age 12 will not be allowed to receive mental health/substance abuse services without parental consent.

Illinois Consent and Confidentiality Laws allow minors over age 12 to receive sexually transmitted infection (STI) testing and treatment and pregnancy testing without the consent of a parent or guardian. The staff of the SBHC considers parental involvement extremely important. We encourage all students to involve their parent or guardian in health care decision making.

Confidentiality of student records and medical information will be maintained as required under the relevant Federal and State laws and regulations.

I consent to the release of relevant health information about the student to Advocate Medical Group to facilitate evaluation of the student's health needs and to further medical services provided to the student at the School-Based Health Center.

I authorize the School-Based Health Center to release information regarding my child's treatment to third party payers or others for purposes of billing, program management and evaluation in accordance with all federal and State laws and regulations. I further authorize for the release of any immunization records or copy of the Child Health Examination record between the School based Health Center and District 207 High Schools.
Signature of Parent/Guardian for Consent for care at SBHC:

Clear
I agree that my child receives telehealth services, if appropriate. They may stop, or refuse these services at any time.
Type Initials Here to consent to telehealth
Date

MonthDayYear
Date
Relationship to Student

MotherFatherOther (specify)
Should be Empty: