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School Health Consent Form


Urban Community School (“UCS”) 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
Legal Guardian Information (this will be the primary person contacted concerning the student’s health)
Student/Patient Insurance Information (if known):
Emergency Contact Information (other than legal guardian):
Student Health Information (to be completed by parent/legal guardian)
Primary Care Provider Information
Preferred Retail Pharmacy:
Student/Patient Allergies and Immunization History
Services: Additional school-based health services may include the following services unless you tell us not to.
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 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.


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.

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 read and understand the information about the School-Based Supplemental Health Services provided through the MetroHealth School Health Program. My signature provides consent for my child to receive the Services for as long as my child is a student in UCS. I understand that I can revoke my consent at any time by providing a written request to The MetroHealth School Health Program.

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 UCS staff involved in the operation, administration, and evaluation of its health program. These UCS staff may include nurses, physical therapists, occupational therapists, speech therapists, psychologists, social workers, health coordinators, researchers, and other administrative staff (together, the “UCS Health Personnel”). MetroHealth’s communications with UCS 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 UCS 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 UCS 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 UCS 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 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: 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 UCS OR UNTIL I TERMINATE IT IN WRITING.



Electronic Signature


 

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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