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Cleveland Metropolitan School District (“CMSD”) and Say Yes Cleveland (“SYC”) partner with community agencies to offer additional School-Based Health Services. Completion of this consent form is required for your child to receive these health services from CMSD partner health providers. 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:

Student Date of Birth:

Student Sex:

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 Employer Name (if available):

Guardian’s Employer Phone (if available):

Guardian’s Phone Number:

Guardian's Email Address:

Guardian's Relationship to Student:

Guardian lives with 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 additional School-Based Health Services (the "Services") listed below when necessary to promote my child's health. I understand that these Services will be performed by a health provider in partnership with CMSD and that contact information for all partner health providers can be found on CMSD's website at https://www.clevelandmetroschools.org/Page/19754. 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 any of the 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.

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 CMSD partner providers to seek payment in a timely manner. These Services are provided to students whether or not a student has insurance or the ability to pay. I give CMSD partner providers 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. I have read and understand the information about additional School-Based Health Services available through CMSD partner health providers. My signature provides consent for my child to receive the Services for as long as my child is a student in CMSD. I understand that I can revoke my consent at any time by providing a written request to CMSD.

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 CMSD partner health providers to provide my child's medical information, including diagnosis, treatment records, vaccinations, and lab results, to CMSD school officials, including SYC staff and third parties, engaged in the facilitation of CMSD's student health and wellness initiatives, for treatment, referral, and/or care coordination. I authorize CMSD and SYC to provide a copy of medical information or other relevant personal information within my child's school records to CMSD partner health providers. I agree to allow CMSD partner health providers to access my child's individual academic, attendance, and behavior records for the current and prior school years so they can provide better services to my child. 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 use treatment. CMSD partner health providers 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, that I do so of my own free will, and that if I refuse to sign this authorization to disclose my child’s information, it will not in any way prevent my child from receiving care or treatment from any of the providers listed. I understand that I may terminate this authorization in writing at any time, prior to the release of my child’s information, though such termination would not impact information released prior to the submission of a written termination notice. I am also aware there is potential for information disclosed under this consent 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 CMSD partner health providers. I know that I can also view them online at https://www.clevelandmetroschools.org/Page/19754. I understand that the terms of the Privacy Notice may change and I may get these changed notices by contacting CMSD partner health providers 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 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 CMSD 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.

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