I give my consent for my child, named above, to receive medical care from the school-based health program. I understand that as a participant the providers, the school nurse and your child’s main health care provider may communicate by special video equipment with other physicians and health care professionals at other Health Care Centers in Schools’ (HCS) sites.
I consent to and authorize the physician(s), physician assistant(s), nurse practitioner(s), resident physician(s), healthcare student(s), and clinical staff to provide diagnostic procedures and medical treatment including, but not limited to minor procedures and routine services deemed necessary at the time of the office visit, to me or the patient named on this form. I understand that the practice of medicine is not considered exact science and acknowledge that no guarantees have been made to the patient named on this form.
Medical Education* I agree that care may be provided by student nurses, technicians, therapists, interns, residents, fellows and other providers and observers, which are supervised by qualified faculty in accordance with organizational policies.
Photography and Other Recordings* I consent to photographs, audio, and video recordings, digital or other images that may be recorded to document my care. I understand that these images may be used for case study and research. I understand that these images will be stored in a secure manner and will be released when requested for non-treatment reasons, only upon written authorization by me, or my legal representative. I consent to having part of my care be provided by use of video equipment, without the physician being physically present in exam room.
Authorization for Healthcare-Related Calls, Texts and E-mails I, the undersigned, hereby authorize and consent to employees, agents, representatives, affiliates, business associates, and/or designees contacting me using prerecorded/artificial voice messages and/or automatic dialing services at any telephone number (including a wireless telephone) that I provide. This consent and authorization will apply to text messages sent to the wireless numbers I provide and to e-mails using any e-mail address that I provide. I understand that texting or emailing to the numbers and addresses I provide may not be secure. This consent and authorization will apply to the current visit and any future visits. This consent and authorization is valid until revoked by me, in writing, by certified mail sent to the following address:
FMOLHS ATTN: Customer Service Team
5959 S. Sherwood Forest Blvd.
Baton Rouge, LA 70816
I agree that the services listed on page 3, unless noted in writing may be provided to my child.
I have completed the Patient Demographic Form (see page 4) and authorize Health Care Centers in Schools to bill Medicaid or other insurance providers for these services. I assign payments of authorized benefits directly to HCCS. I understand that I will not be charged for any of the services provided through the health center that are not covered by insurance.
I understand that Health Care Centers in Schools programs may participate in one or more health information exchanges (HIEs), whereby the clinic may share my health information with other health care providers for treatment, payment, or health care operations purposes.
I also understand that the Office of Public Health (“OPH”), Adolescent School Health Program provides oversight to School Based Health Clinic’s (SBHCs) and, as part of such program; the Health Care Centers in School’s Clinics are required to provide information to OPH. Therefore, we consent to the disclosure of SBHC information to OPH, or its agent, in connection with the operation, funding and ongoing monitoring of school-based health centers. We recognize that the information needed by OPH may be compiled through a health information exchanges (HIE) and consent to the disclosure of information to a HIE for such purpose. I understand that the School Based Health Clinic (SBHC) may participate in one or more HIEs, whereby the clinic may share my health information with other health care providers for treatment, payment or health care operations purposes. We hereby consent to the disclosure of the SBHC’s records into the HIEs.
Louisiana Law R.S. 40:31.3 states that Health Centers in schools are prohibited from:
- Counseling or advocating abortion or referral of any student to an organization for counseling or advocating abortion.
- Distributing any contraceptive or abortifacient drug device, or similar product.
To report violations of the prohibitions against abortion counseling, advocacy, or referral; or distribution of contraceptives, abortifacient drugs, devices, or other similar products, contact the Adolescent School Health Program at the Office of Public Health at 504-568-3504.
I understand that there will not be payment required for any of the services provided at the school-based health center. I also understand that Health Care Centers in Schools or the provider will bill Medicaid or other insurance providers for these services. I authorize/assign payments of authorized benefits directly to HCS.
BY SIGNING THIS CONSENT, YOU ARE AGREEING TO ALLOW HEALTH CARE CENTERS IN SCHOOLS TO PROVIDE THE FOLLOWING SERVICES TO YOUR CHILD:
- Primary and preventive health care (including immunizations)
- Comprehensive history and physical examinations health screenings
- Laboratory/diagnostic testing
- Case management
- Acute care for minor illness/injury (including medications), if indicated
- Hearing & Vision screening
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- Management of chronic diseases
- Behavioral health services
- Referral and follow-up for emergencies
- Referral to specialty care
- Health education & prevention programs
- Dental services (where available)
- Telehealth visits with a primary care, specialty, or behavioral health care provider
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