Informed Consent for Schools
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.
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 www.shalomhealthcenter.org as well as each of our clinics.
We may use or share your child’s information for the following:
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:
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
HEALTH HISTORY FORM-MEDICAL INFORMATION
Student’s Full Name: __
Date of Birth: / / Race:
Student Address: , , ,
Student Current School:
Allergies (food, medication, insects, etc.):
Preferred Pharmacy: (include intersection if unsure of address)
Primary Care Provider: Phone:
Birth Defects YesNo
Bladder/Kidney Infections/Disease YesNo
Blood Disorder YesNo
Headaches and Migraines YesNo
Hearing Problems(hearing aids or devices YesNo
Heart Disease/Murmurs YesNo
Sickle Cell Anemia YesNo
Skin Disorders YesNo
Vision Problems(glasses or contacts) YesNo
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:
Relationship to student:
Family’s Total Gross Income before taxes: per WeekBiweekMonthYear
How many people does this income support Does your child qualify for the free lunch program? YesNo
*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 YesNo
Company Name: Member #
No Insurance YesNo
***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
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.
(Parent’s initials) I acknowledge that I have received a copy of the Shalom Health Care Center Inc.
SERVICES WILL NOT BE PROVIDED WITHOUT A SIGNED PARENTAL/GUARDIAN CONSENT AS REQUIRED BY THE INDIANA STATE LAW.
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Informed Consent for Schools
Agree & Sign