RRH School-Based Health Center Enrollment

Student Health Insurance Information

Does your child have medical coverage?

Select the insurance plan you have.

What is the insurance ID number?

If you do not have insurance may someone contact you to assist with insurance enrollment? A SBHC team member will work with you to obtain insurance for your family, for free!

CONSENT TO TREATMENT

I consent for my child to receive health care services provided by Rochester Regional Health as part of the School-Based Health Center program approved by the New York State Department of Health. I understand that confidentiality between the student and the health provider will be ensured in specific service areas in accordance with the law, and that students will be encouraged to involve their parents or guardians in counseling and medical care decisions. I further authorize the exchange of medical information with other medical providers who have examined the child named on this form and our insurance provider. School-Based Health Center services may include, but are not limited to:

Comprehensive physical examination (complete medical examination) including those for school, sports, working papers and new entrants.
Medically prescribed laboratory tests such as for anemia, sickle cell, and diabetes.
Medical care and treatment, including diagnosis of acute and chronic illness and disease, and dispensing and prescribing of medications.
Mental health services including evaluation, diagnosis, counseling, and referrals.
Reproductive health care services, including contraception, (birth control pills, Depo (the shot) etc, testing for pregnancy, STD screening and treatment, HIV testing, PAP smears, and referrals for abnormal results, as age appropriate.
Nutrition and weight counseling.
Health education and counseling for the prevention of risk-taking behaviors such as: drug, alcohol and smoking abuse, as well as education on abstinence and prevention of pregnancy, sexually transmitted infections, and HIV, as age appropriate.
Referrals for service not provided at the school based health center.
Refractive vision screening for prescriptive eyewear.
Access to care is available 24 hours a day, seven days a week. Call 585-922-SBHC.

I have read and understand the services listed above and my signature below documents consent for my child to receive services provided by the School-Based Health Center. NOTE: By law, parental consent is not required for the conduct of mandated screenings, the application of first aid treatment, pre-natal care, services related to sexual behavior and pregnancy prevention, and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students who are 18 years or older or for students who are parents or otherwise legally able to sign on their own behalf. You may view Rochester Regional Health’s Notice of Privacy Practices and Patient Bill of Rights at

https://www.rochesterregional.org/patients-visitors/patient-forms

Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law)

By typing your name above you are legally binding an e-signature.

I have read and understand the services listed above and my signature below documents consent for my child to receive services provided by the School-Based Health Center. NOTE: By law, parental consent is not required for the conduct of mandated screenings, the application of first aid treatment, pre-natal care, services related to sexual behavior and pregnancy prevention, and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students who are 18 years or older or for students who are parents or otherwise legally able to sign on their own behalf. You may view Rochester Regional Health’s Notice of Privacy Practices and Patient Bill of Rights at https://www.rochesterregional.org/patients-visitors/patient-forms

Today's Date

Date

Hour MinutesAM/PM Option

CONSENT TO TELEMEDICINE AND TYTO CARE SERVICES

By completing this form, you (student or parent/guardian) are providing consent for the student(s) to receive health care services via a telemedicine visit with RRH. This permission will remain in effect until the student is no longer registered at the school or until it is withdrawn in writing to RRH or RCSD’s General Counsel.

Confidentiality: The laws that protect privacy and the confidentiality of medical information also apply to telemedicine. The telemedicine provider and their agents will respect patient privacy and confidentiality during this electronic exchange of information. The information captured will be maintained, stored and safeguarded in the same fashion as any face-to-face or other form of interaction between a patient and health care provider. By signing below, you give RRH permission to use and disclose health information for treatment, payment and RRH health care operations. RRH will not record any visit without consent. Any recorded images needed for evaluation, diagnosis or treatment purposes created during a telemedicine visit will not be displayed, broadcast, or otherwise shown outside the health care setting without additional authorization. While RRH encourages every patient to involve parent(s)/legal guardian(s) in all treatment decisions, certain information must remain confidential unless the student consents to disclosure of such information to parent(s)/guardian(s).

Read our full telemedicine patient rights and responsibilities at https://www.rochesterregional.org/patients-visitors/patient-forms

Telemedicine Services: Telemedicine visits with RRH may include, but are not limited to, the following services:

Respiratory Issues: (allergy/asthma, cough, congestion, sore throat, COVID symptoms)
Infections: (ear/nose/throat, skin, pink eye)
Mild traumas: (cuts/abrasions, aches/pains, sprains/strains)
Topical / Dermatological Issues: (rash/poison ivy, burns/abrasions, skin infection, bites)
Routine Follow-up for Chronic Conditions: (ADHD, anxiety, asthma, diabetes mellitus, obesity)

By signing below, I am agreeing that I have read and fully understood the contents of this document and all of my questions have been answered. I consent to the student listed below receiving telemedicine services as described in this document:

Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law)

By typing your name above you are legally binding an e-signature.

Today's Date

Date

Hour MinutesAM/PM Option

I give my consent to the school nurse to administer the following medications as ordered by the SBHC Nurse Practitioner and/or physician after a telemedical appointment. Medication orders expire at the end of the school day on the day of SBHC clinic appointment.

Acetaminophen (Tylenol) 15mg/kg Ibuprofen (Motrin/Advil) 10mg/kg
Benadryl antihistamine (for generalized allergic reaction) 5mg/kg /day (divided into 3 or 4 doses) Loratadine 10mg
Triple antibiotic ointment Saline (salt water gargle) mouth rinse Benadryl or cortisone cream (topical itching/rash)
Tums antacid
Cough Drops

Student's Name

First NameLast Name

Student's Date of Birth

Date

Signature of Parent/Guardian

By typing your name above you are legally binding an e-signature.

Today's Date

Date

Hour MinutesAM/PM Option

I'd like to be notified when medication is administered

Youth and Family Forms

School-Based Health Center Enrollment

Student Information

Parent/Guardian Information

Student Medical History

Student Health Insurance Information

CONSENT TO TREATMENT

School-Based Health Center Mental Health Services Referral

Family Peer Advocate Referral

Community Youth Behavioral Health School Referral Form

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