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School-Based Health Center Student Registration & Permission Form

Parent or Court Ordered Legal Guardian Information
Name(Required)
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Student Information

Name(Required)
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Address(Required)
Emergency Contact(Required)

Student Medical History

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If Yes, Please Consent to the Statement Below:
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Household Information

Family Medical History

Notice and Acknowledgment of Privacy Practices

Available upon request and on our website www.compassionhealthcare.org, you will find a Notice of Privacy Practices that details the way we keep your child’s medical record confidential, and what rights you have to access that medical record. You will also find a form listing Student and Parent Rights & Responsibilities. We are required by Federal Law to provide you with this information, and we ask that you read the Notice of Privacy Practices and Rights & Responsibilities for both you and your child. Please call (336) 694-9331 to speak to our CHC Privacy Officer if you have any questions. Thank you for your cooperation in our effort to comply with this law.

Insurance Information

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Insurance Company Address (To Mail Medical Claims - Check on Back of Your Insurance Card)
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Employer Address
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    Authorizations and Consents

    I give consent for my child to receive any of the available services at the CHC School-Based Health Center. The CHC School-Based Health Center provides medical, services to enrolled students who have completed registration, including written consent and signature of the parent or legal guardian. Staff of the CHC School-Based Health Center will inform parents of significant findings and treatment recommendations for minor children, for conditions other than those exempted by state law. For your convenience and at your request, some services may be provided by telehealth.
    Consent
    I authorize the release of information to my child’s primary care provider, School Nurse, and the school’s Student Support Services any medical information pertinent to my child’s general health and care while they are at school. I authorize the release of the minimum necessary information from my child’s primary care health provider, School Nurse, and the school’s Student Support Services to the CHC School-Based Health Center for coordination of care.
    Consent
    I authorize the release of any medical information, including information on communicable diseases information necessary to process an insurance claim for payment of benefits to the CHC School-Based Health Center.
    Consent
    I authorize payment of insurance benefits for services rendered at the CHC School-Based Health Centers, though Compassion Health Care, Inc.
    Consent
    I understand that CHC. operates the School-Based Health Center, and I must contact CHC to make special payment arrangements if I am unable to pay the bill in full.
    Consent
    I understand that all my child’s records will be strictly confidential, and maintained in compliance with state and federal laws, including HIPAA and any paper records will be maintained onsite at the CHC School-Based Health Center Unit. Information is only shared with those individuals you give permission to receive.
    Consent
    I confirm that all information given is complete and accurate.
    Consent
    By signing this form, I authorize my child to receive all services available from the School-Based Health Center. I understand that this consent is voluntary, and I may also revoke my consent, in writing, at any time. I understand that it is my responsibility to provide up-to-date information on the insurance coverage I carry on my child, including Medicaid and any Medicaid Managed Care plans. I also understand that I am financially responsible for all charges and any co-pays or deductible amount not covered by my insurance. I further understand that I am responsible for understanding my own insurance plan and whether services are covered or require pre-authorization. If services require pre-authorization, I understand this is my responsibility.

    Sliding Fee Application

    SLIDING FEE

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