School Health Program Consent Form

Consent for Health Services/Treatment

By signing below, the Parent/Guardian consents for your child to receive the necessary and/or advisable School-Based Supplemental Health Services listed below in this section of the Consent Form (the "Service") from a MetroHealth physician or healthcare provider through MetroHealth's School Health Program. The Parent/Guardian understands that he/she has the opportunity to ask and have any questions answered about the risks, benefits, and alternatives of the Services by contacting MetroHealth at (216) 957-1303 and that MetroHealth recommends the Parent/Guardian do so prior to signing this Consent Form if he/she has any questions about the Services. The Parent/Guardian further understands that examination and treatment may be in-person or by telehealth. The Parent/Guardian acknowledges and understands that by signing this Consent Form, he or she is consenting to the Services and/or immunizations directly below. If there are particular services or immunizations you do not want your child to have, please circle those services.

Agreement of Financial Responsibility

Some School-Based Supplemental Health Services are provided at no cost to families whether or not a student has insurance or the ability to pay. You may get a bill for some services if not covered by insurance. If applicable, MetroHealth will bill your child’s insurance carrier(s) for charges and fees covered by your child's insurance plan. Parent/Guardian agrees to provide complete, accurate and timely information relating to any available health insurance in order for MetroHealth to seek payment in a timely manner. Parent/Guardian understands that a failure to provide complete, accurate and timely information, including any changes in insurance coverage, may prevent the provider from complying with the administrative rules of your child’s insurance plan. Parent/Guardian may obtain a list of usual and customary charges from MetroHealth upon request.

I, PARENT/GUARDIAN, CERTIFY THAT I AM OF SOUND BODY AND MIND, THAT I HAVE READ THIS CONSENT FORM, THAT I HAVE RECEIVED INFORMATION ON THE PATIENT BILL OF RIGHTS AND RESPONSIBILITIES, INCLUDING THE PROCESS FOR FILING A COMPLAINT OR GRIEVANCE, THAT I UNDERSTAND AND AGREE WITH THE INFORMATION CONTAINED IN THIS CONSENT FORM, INCLUDING BUT NOT LIMITED TO THE CONSENT FOR HEALTH SERVICES/TREATMENT AND FINANCIAL RESPONSIBILITY SECTIONS, AND THAT I FREELY GIVE MY INFORMED CONSENT FOR MY CHILD TO RECEIVE THE RECOMMENDED SUPPLEMENTAL HEALTH SERVICES.

Authorization to Release Health Information

I authorize MetroHealth to provide my child's medical information, including diagnosis, treatment records, vaccinations, and/or lab results to CH-UH Health Personnel for treatment, referral, and/or care coordination. To help coordinate care, I also authorize Cleveland Heights- University Heights City School District staff to provide a copy of medical information or other relevant personal information within my child's school records to MetroHealth to facilitate the assessment of my child's health needs, coordinate my child's care, provide treatment or referral, and/or evaluate the School Health Program and its services. I also agree to allow MetroHealth access to my child's individual academic, attendance, and behavior records for the current and prior school years so it can provide better services to my child. This permission will expire when your child is no longer an enrolled student in the Cleveland Heights-University Heights City School District or when it is terminated in writing. I understand that my express consent (or in some cases, my child's express 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/or drug or alcohol abuse treatment. If you have consented for your child to be tested, treated, or diagnosed with any such injury, disease, or illness, MetroHealth is specifically authorized to disclose information relating to such diagnosis, testing, or treatment, as directed in this Authorization. For records related to alcohol and drug treatment, federal law prohibits recipient from making further disclosure of this information unless the additional disclosure is expressly consented to in writing by the person to whom it relates or as otherwise permitted by federal law. I understand that I am not required to sign this authorization, that I do so of my own free will, and that if I refuse to sign this authorization to disclose my child's health information, it will not in any way prevent my child from receiving care or treatment from MetroHealth or appropriate CH-UH 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 aware there is potential for information disclosed under this consent to be redisclosed by the recipient and no longer be protected.