Hometown Health Centers, Schenectady
School-Based Health Center Consent Form

SCHOOL-BASED HEALTH CENTER SERVICES

I provide consent for my child to receive health care services in the Schenectady School District’s Mont Pleasant school-based health center (SBHC). Physicians and Nurse Practitioners employed by Hometown Health Centers staff the SBHC program which is licensed by the New York State Department of Health.  Services provided by the SBHC include:

• Screenings for vision, hearing, asthma, obesity, scoliosis, Tuberculosis and other medical conditions, first aid, and required and recommended immunizations by the CDC.
• Comprehensive physical examination including those for school, sports, working papers, etc.
• Medical care and treatment, including diagnosis of acute and chronic illness and disease.
• Mental health screenings and referrals for evaluations.
• Medically prescribed laboratory tests and medications.
• Reproductive health care services, including abstinence counseling, contraception, testing for pregnancy, STD screening and treatment, HIV testing, and referrals for abnormal results, as age appropriate.
• Health education and counseling for the prevention of risk-taking behaviors such as: drug, alcohol, and smoking abuse, as well as education on abstinence and prevention of pregnancy, sexually transmitted infections, and HIV, as age appropriate. 
• Annual health assessment.
• Referrals for service not provided at the school-based health center.

I understand that confidentiality between the student and the health provider will be ensured in specific service areas in accordance with the law, and the students will be encouraged to involve their parents or guardians in counseling and medical care decisions.  

I give permission for necessary medical tests, evaluations, and management of my child’s medical care. As mandated by the Education Law Article 19 and the Regulations of the Commissioner, health examinations for students entering into Kindergarten, grades 2,4,7,10 and sports physicals will be shared with the school nurse. Additional health information will be shared with the school nurse only on a need to know basis as determined by the SBHC Medical Director to secure the child’s health and welfare.  The student’s health center record will be maintained as a confidential medical record; it is not a school record. I also understand that confidentiality will be observed between school staff and the students using the SBHC.

I authorize Hometown Health Centers to release information regarding treatment to third party payers or other for purposes of billing and for any reason that may be required to comply with statutes or regulations in accordance with accepted medical practices.

I have read the above information and have had the opportunity to have any of my questions answered. I understand that this consent form will remain in effect as long as my child is enrolled in Hometown’s SBHC program, unless I notify the Health Center in writing. I understand that I may revoke my consent at any time.

By law, parental consent is not required for prenatal care, services related to sexual behavior, mental health care and pregnancy prevention, and the provision of services where the health of the student appears to be endangered.  Parental consent is not required for students who are 18 years or older or for students who are parents or legally emancipated.