Informed Consent for Schools

Attention Parents/Guardians-

Your student’s school and Shalom Health Care Center have joined forces to operate a school- based health clinic, providing access to quality health services for students. It is our goal to help your family by providing medical services for your child while they are in school, assisting your child’s physician with their healthcare needs, and providing access to healthcare for those who do not have any healthcare services.

Our clinics are staffed with RNs, LPNs, or Nurse Practitioner’s with a Medical Assistant (in certain clinics). A Nurse Practitioner is an advanced practice nurse with a Master’s degree or higher, that has been trained to diagnose and treat.

Our services are not intended to replace your child’s primary care provider. Our intent is to expand access to healthcare by working with families and their health providers to offer quality health care in the school setting.

In accordance with Indiana State Law, all families wishing to receive health services from Shalom’s school-based clinics (sbc) must sign a consent to treat form. We also ask that you fill out a brief medical history form to provide our medical staff with the most up-to-date medical information for your child. Any information given will remain confidential as part of your child’s medical record.

This consent form is accepted at any school with a Shalom SBC, good through the student’s senior year of high school. A written request to withdraw consent for treatment must be completed by the parent or guardian in order to discontinue services. The parent or guardian is responsible for notifying the clinic of any changes to the student’s health history, guardianship and/or demographic information.

This program is provided at no cost to you or your family. Shalom will bill and collect from Medicaid and other third party health insurances your child may have. We do require insurance information be provided in order to provide services. This ensures our ability to continue school- based clinic services and care for your child.

Thank you for your cooperation and allowing us to participate in your child’s health care needs.



Notice of Privacy Practices Summary

This summary describes how Shalom uses and shares your child’s information and how you may acquire copies of this information. The full Notice of Privacy Practices is available at as well as each of our clinics.

We may use or share your child’s information for the following:

  • Treatment-such as discussions of your child’s care amongst the medical
  • Payment-such as billing insurance for services provided to your
  • Operations-such as working to improve our quality of care, advertising services provided,etc.
  • Other ways- such as mandatory disease reporting to county andstate health officials, responding to court requests, appointment reminders, test result letters,

Exceptions- Different laws may apply to mental health, family planning, drug and alcohol and AIDS/HIV treatment.

Any other reasons for use or sharing of your child’s health information will be completed only with your specific written permission or as required by law.

Regarding your child’s information, you have the following rights:

  • Requesting restrictions on how your child’s information is shared. Shalom is not required to agree to requested restrictions, but will notify you if we cannot accommodate your
  • Acquire and inspect a copy of your child’s health
  • Ask that incorrect or incomplete information in your child’s medical record be
  • Ask that we contact you by mail or phone to an alternate address and/or phone
  • Change your mind if you previously granted sharing/use of your child’s information for reasonsother than those listed
  • Receive a list of the times we shared your child’s information. This list will only contain the times that the law requires us to


As we serve our patients, we may change how we handle your child’s information. If we make any changes, we will give you a new notice the next time you visit our clinic. You may call or write at any time to check if we have made any changes.


If you believe that your privacy rights have been violated, you may file a complaint with Shalom’s Privacy Officer. You may also file a complaint with the U.S. Department of Health and Human Services. Your care will not be affected in any way if you choose to file a complaint.

Please address questions or complaints to:

Shalom Privacy Officer

3400 Lafayette Road, Suite 200

Indianapolis, IN 46222

(317) 291-7422



Student’s Full Name:     __



Date of Birth:  / / Race:   

Email Address: 


Student Address:  , , ,

Student Current School:

Current medication(s) 

Allergies (food, medication, insects, etc.):  

 Preferred Pharmacy: (include intersection if unsure of address)   

Primary Care Provider:  Phone:  



Birth Defects

Bladder/Kidney Infections/Disease

Blood Disorder



Headaches and Migraines

Hearing Problems(hearing aids or devices

Heart Disease/Murmurs


Sickle Cell Anemia

Skin Disorders

Vision Problems(glasses or contacts)



Mental Health Conditions (ADHD/Autism/Eating Disorders/Depression etc.)

If YES, do they see a mental health specialist? 


Other important Health Information


Contact Names and Phone Numbers in case of need:





Emergency Contact:

Relationship to student: 

Phone #

Family’s Total Gross Income before taxes:  per  

How many people does this income support  Does your child qualify for the free lunch program?  


*We are required as an FQHC (Federally Qualified Health Center ) to attempt to collect this information for data reporting only. Submissions remain anonymous*


What type of health insurance does your child have? REQUIRED (YOU WILL NOT RECEIVE A BILL)


                            If yes, Medicaid Number#(required):   

Private Insurance

                            Company Name:   Member # 

No Insurance


**Insurance information is required to participate in Shalom School-based clinic program**


***Shalom’s School-Based Clinics have over the counter medications in stock (e.g. Tylenol, ibuprofen, hydrocortisone cream etc.) that may be made available to your child depending on their symptoms. If you DO NOT wish the clinic to provide your child any over the counter medications please initial here:

        I DO NOT permit Shalom SBC staff to provide my child with over the counter medication

Informed Consent for School-Based Health Clinic Services

as provided by Shalom Health Care Center Inc.


I give permission for (student’s full name)    to receive health services from the school-based clinic (SBC) at my child’s school. I understand that the school- based clinic provider does not replace my child’s Primary Care Provider and cannot take care of all my child’s health care needs.

  1. I have read the information provided regarding the school-based health clinic and the release of information and I understand what services the clinic will and will not provide. My consent will allow my child to receive health services while he/she is a student at any school with a Shalom SBC. I understand that if I chose to cancel these services, I must provide the request in writing. It will be my responsibility to notify the clinic staff regarding changes in guardianship, contact information and health history.


  1. Information Privacy : I have been informed that Shalom has prepared a detailed NOTICE OF PRIVACY PRACTICES regarding my child’s personal health I understand that the terms of the notice may change, and current notices will be available on Shalom’s website and facilities.


  • Release of Information: I understand the services provided by the school-based health care clinic are confidential. The clinic will use and disclose my child’s personal health information to provide treatment and for improvement of healthcare operations. My child’s information may be shared with my child’s physician/provider, appropriate school staff, or with my child’s insurance provider for legitimate purposes. I authorize the release of my child’s medical information to other providers who may have my child as a patient. I also authorize the use of information from my child’s medical record for purposes of medical care, treatment, clinic administration and evaluation. In addition, I give my consent to the clinic staff to look at, and update my child’s school health record,


                   (Parent’s initials) I acknowledge that I have received a copy of the Shalom Health Care Center Inc.




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Document name: Informed Consent for Schools
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March 5, 2019 5:39 pm EDTInformed Consent for Schools Uploaded by Darren Huff - [email protected] IP
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