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The Brooklyn City School District (“BCSD”) partners with The MetroHealth System (“MetroHealth”) to offer School-Based Supplemental Health Services. Completion of this consent form is required for your child to receive supplemental health services. School nursing and emergency services will be provided whether or not you choose to take part in these added services.

This form will time out after 20 minutes, and anything not yet submitted will be lost. Please have the student/patient's insurance and pharmacy information ready before you begin.

**All fields marked with * are required fields**

Student/Patient Information

Student First Name:

Student Last Name:

Social Security #:

Student Date of Birth:

Student Sex:

Gender:

Student Home Address:

Student City:

Student State:

Student Zip Code:

Student Home Phone Number:

Student School Name:

Student Preferred Language:

Is this student Hispanic/Latino?

Student Race:

Legal Guardian Information (this will be the primary person contacted concerning the student’s health)

Guardian’s First Name:

Guardian’s Last Name:

Guardian’s Date of Birth:

Guardian’s Social Security #:

Guardian’s Employer Name (if available):

Guardian’s Employer Phone (if available):

Guardian’s Cell Phone (if available):

Guardian’s Phone Number:

Guardian's Relationship to Student:

Student/Patient Insurance Information (if known):

Student has insurance?

Name of Insurance Company:

Subscriber's Name:

Group Number:

Subscriber Number:

Emergency Contact Information (other than legal guardian):

Full Name:

Phone Number:

Relationship to Student:

May we leave a message?

Student Health Information (to be completed by parent/legal guardian)

Please select all that apply (to select multiple items, hold down the CTRL key and then click on each item)

Other (please explain)

Primary Care Provider Information

Name of Primary Care Provider/Physician (PCP):

PCP Location

Preferred Retail Pharmacy:

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

Student/Patient Allergies and Immunization History

Does the student/patient have any allergies?

Please select student/patient's allergies (to select multiple items, hold down the CTRL key and then click on each item)

Has the student/patient ever had a reaction to any immunization/shot?

If YES, please explain

List immunization/shot that caused reaction

Services: Additional school-based health services may include the following services unless you tell us not to.

Please select any services you DO NOT want the student to receive:

Immunizations (shots): The student/patient's school nurse and the MH School Health Program will review the student/patient's record to determine which shots are needed. We will provide additional immunizations unless you tell us not to.

Please select any shots you DO NOT want the student/patient to receive (to select multiple items, hold down the CTRL key and then click on each item)

Please select any School-Required Immunizations you DO NOT want the student to receive:

Please select any Pediatric/Adolescent Recommended Immunizations you DO NOT want the student to receive:

Please visit https://www.immunize.org/vis to find the Vaccine Information Statement for each vaccine, which will explain risks and benefits of all vaccines.

Consent for Health Services/Treatment and Agreement of Financial Responsibility

Consent for Health Services/Treatment

By signing below, I consent for my child to receive the School-Based Supplemental Health Services (the “Services”) listed below when necessary to promote my child’s health. I understand that these Services will be performed by a MetroHealth provider through MetroHealth’s School Health Program. I also understand that examination and treatment may be in-person or by telehealth. Treatment received using telehealth does not allow for direct contact with a patient and may be affected by transmission quality. If I no longer want my child to receive telehealth services, I may request that they be stopped, and that request will not affect my ability to obtain medical care for my child in the future. I understand that I can ask any questions about the Services by contacting MetroHealth at (216) 957-1303.

Agreement of Financial Responsibility

Insurance or other health care coverage programs are billed whenever possible to help cover the cost of care. If applicable, I agree to provide complete, accurate and timely information relating to any available health insurance in order for MetroHealth to seek payment in a timely manner. These Services are provided to families whether or not a student has insurance or the ability to pay. I give MetroHealth the right to submit claims for reimbursement under any private health insurance policy, Medicare, Medicaid or any other programs that I identify for which a benefit may be available to pay for services provided to my child through the School Health Program.

I have reviewed and acknowledged and consent to the terms described above. I confirm that I am the patient named above (or if the patient is a minor child, the patient's parent or legal guardian named above) and I understand and agree that by checking the box below, I am electronically signing this Consent for Health Services/Treatment and Agreement of Financial Responsibility section and an electronic signature has the same effect as my written signature.

Click here to agree to the Consent for Health Services/Treatment and Agreement of Financial Responsibility

Authorization to Release Health Information and Notice of Privacy Practices Acknowledgement

Authorization to Release Health Information

I authorize MetroHealth to provide my child’s medical information, including diagnosis, treatment records, vaccinations, and lab results, to BCSD staff involved in the operation, administration, and evaluation of its health program. These BCSD staff may include nurses, physical therapists, occupational therapists, speech therapists, psychologists, social workers, health coordinators, researchers, and other administrative staff (together, the “BCSD Health Personnel”). MetroHealth’s communications with BCSD Health Personnel will be made to help with my child’s treatment, referral, and care coordination and to assist with evaluation of the School Health Program and its services.

I also authorize BCSD staff to provide a copy of medical information or other relevant personal information within my child’s school records to MetroHealth so MetroHealth can better understand my child’s health needs, coordinate my child’s care, provide treatment or referral, and evaluate the School Health Program and its services. The information BCSD provides to MetroHealth may include access to my child’s individual academic, attendance, and behavior records.

I understand that my child’s consent may be required for the disclosure of certain diagnosis and treatment information relating to sexually transmitted diseases, AIDS, HIV, mental illness, psychiatric treatment, and drug or alcohol abuse treatment. MetroHealth may only disclose information relating to such diagnosis, testing, or treatment as directed in this authorization and as allowed under applicable law.

I understand that I am not required to sign this authorization, and I do so of my own free will. If I refuse to sign this authorization, it will not in any way prevent my child from receiving care or treatment from MetroHealth or appropriate BCSD Health Personnel. I understand that I may terminate this authorization in writing at any time prior to the release of my child’s health information. I am also aware there is potential for information disclosed under this authorization to be redisclosed by the recipient and no longer be protected.

I CERTIFY THAT I HAVE READ THIS AUTHORIZATION TO RELEASE HEALTH INFORMATION AND CONSENT TO THE RELEASE OF MY CHILD'S INFORMATION AS DESCRIBED ABOVE.

Click here to agree to the Authorization to Release Health Information

Notice of Privacy Practices Acknowledgement

I have been notified that I can ask for a copy of the Notice of Privacy Practices forms for The MetroHealth System. I know that I can also view them online at: https://www.metrohealth.org/patients-and-visitors. I understand that the terms of the Privacy Notice may change and I may get these changed notices by contacting The MetroHealth System by phone or in writing. I understand I have the right to ask how my protected health information will be used or given out.

I CERTIFY THAT I HAVE READ THIS AUTHORIZATION TO RELEASE HEALTH INFORMATION AND CONSENT TO THE RELEASE OF MY CHILD’S INFORMATION AS DESCRIBED ABOVE. I FURTHER ACKNOWLEDGE THAT I HAVE RECEIVED INFORMATION ABOUT HOW TO RECEIVE NOTICE OF PRIVACY PRACTICES AS EXPLAINED IN THIS DOCUMENT.

THIS AUTHORIZATION FORM WILL REMAIN VALID WHILE MY CHILD IS ENROLLED IN BC SCHOOLS OR UNTIL I TERMINATE IT IN WRITING.

Click here to agree to the Notice of Privacy Practices Acknowledgement

Electronic Signature

Full Name

For complete information on enrollment, visit the MetroHealth School Health Program webpage. To sign up for MyChart and securely access your child's personalized health information any time, day or night, visit the MetroHealth MyChart webpage.

Asthma
Cancer/Leukemia
Eczema
Migraines
Premature Birth
Sickle Cell
Spine Disorders
Bladder/Urinary Problems
Seizures
Glasses/Contacts
Hearing Aids
Mental Health Concerns
Blood Disorder
Diabetes
Pneumonia
Kidney/Renal Disease
Heart Problem
Developmental Problems
Bowel Disorder
Tuberculosis/TB
Tobacco Use
Substance/Drug Abuse
Past or Current Elevated Lead Level
Other

Brooklyn City Schools

School Health Consent Form