082 - CIS Clinic Consent - Prod

CIS Clinic
Consent Form

By completing this consent form you are agreeing to your child receiving necessary medical attention without parental presence. By signing below, you consent to our school nurse remaining in the examine room with your child during any telehealth services. You further consent to our school nurse sharing potentially protected health information and other medical information maintained by the school nurse as an education record under the Family Education Rights and Privacy Act (FERPA) with clinic and telehealth staff.

Parent or Guardian Information

Parent Name*

Please enter the Parent or Guardian's Name

Parent Email*

Please enter the Parent or Guardian's email

Student Information

Name*

Please Enter the Student's Name

DOB*

Please enter the Student's Birthday

Student School Year*

School*

Please indicate the type of health care coverage your child holds*

Medicaid Private Insurance No Coverage

HIPAA/Release of Information Per Patient’s Assignment

I have acknowledged/received a written copy of the Community Health Care Systems, Inc (CHCS) Notice of Privacy Practices and I authorize any physician/staff employee of CHCS to engage in any verbal or written communication to any/all persons listed below regarding my medical history/care/records/appointments and/or information pertaining to my personal account/billing history with CHCS.

Authorized Name*

Please enter the name of the person you authorize to receive information

Relationship*

Please enter the relationship to the patient

Authorized Name 2

Please enter the name of the person you authorize to receive information

Relationship 2

Please enter the relationship to the patient

Voicemail/Answering Machine

I authorize any physician/staff employee of CHCS to leave health information on a voicemail/answering machine at the following numbers:

Phone*

Please enter a phone number

Location*

(Home, Cell, Work, etc.)

Phone 2

Please enter a phone number

Location 2

(Home, Cell, Work, etc.)

Patient Under Age

Please list any person(s) over the age of 18 that is allowed to bring the minor to office visits and/or labs. If the child is brought to an office visit by a person not listed below, written consent by parent/guardian must be provided at date of visit.

Authorized Name 3*

Please enter the name of the person you authorize to bring the minor to the office visits or labs

Relationship 3*

Please enter the relationship to the patient

Authorized Name 4

Please enter the name of the person you authorize to bring the minor to the office visits or labs

Relationship 4

Please enterthe relationship to the patient