CONSENT & ENROLLMENT FORM

SCHOOL:

GRADE:

Student's Last Name:

Student's First Name:

Middle Initial:

S.S.N.

Student's Date of Birth:

Age

Address:

City:

State:

Zip Code:

PREFERRED LANGUAGE:

English

Spanish

French

Other

EMERGENCY CONTACTS:

Parent/Guardian 1:

Relationship:

Home/Cell:

Work:

Parent/Guardian 1:

Relationship:

Home/Cell:

Work:

Emergency Contact:

Relationship:

Home/Cell

Work:

Email to Register for Parent Portal Access:

INSURANCE:

Medicaid

Commercial (Private) Insurance

No Insurance

Name of Insurance Company

Insurance/Medicaid Policy ID #

Select ONE:

Aetna Healthy Blue LA LA Healthcare Connections United Healthcare Humana AmeriHealth Caritas

Insurance/Medicaid Policy ID #

Phone:

Name of Policy Holder:

Relationship to Student

Policyholder’s Birthdate:

Policyholder’s Social Security #

Does your insurance pay for prescriptions?

Yes No

Please attach a copy of your insurance card front and back to this application for School-Based Health services. Services are provided for students at no out-of-pocket cost to parents. Insurance/Medicaid will be billed.

Preferred Pharmacy (Name & Location)

Phone:

Student’s Primary Care Provider:

Phone:

Please check if student does not have a Primary Care Provider

Student’s Therapist or Psychiatrist:

Phone:

Student’s Dental Provider:

Phone:

Do you have access to a smartphone, tablet, or computer?

Yes No

Do you have WIFI access?

Yes No

Please note: All patient privacy notices and Informed Consent for Telemedicine Services are available on request and posted on the School-Based Health Center page online at jpschools.org/SBH

MEDICAL HISTORY

PATIENT HISTORY

(Please Mark any Item That Applies to Your Child’s Medical History)

Birth Defect:

Chicken Pox (if no, vaccine date)

Mental Health Diagnosis, Specify:

FAMILY HISTORY

If Alcoholism/Drug Use is select, which relative?

If Allergies is select, Which relative?

If Anemia is slect, Which relative?

If Asthma is select, Which relative?

If Bleeding Disorders is select, Which relative?

If Cancer, Which relative?

If Depression-Suicide, Which relative?

If Diabetes or Pre-Diabetes, Which relative?

If Genetic Disorder, type and which relative?

If Heart Attack Before Age 55 is select, which relative?

If Heart Disease is select, which relative?

If High Blood Pressure is select, which relative?

If Mental Health Problem is select, List and which relative?

If Seizures is select, which relative?

If Tuberculosis is select, which relative?

If other, specify, and which relative?

ALLERGIES + MEDICATIONS

STUDENT ALLERGIES

(List medicine, food, insect, etc allergies)

Add Allergies

STUDENT MEDICATIONS

Add Medicine

HOSPITALIZATIONS & SURGERIES

Has your child ever been admitted to a hospital for a medical condition?

Add new row

Has your child ever had surgery?

Add new row

BEHAVIORAL HEALTH

Does your child take medication for ADHD, depression, or other mental health problems?

IF YES, PLEASE EXPLAIN

Are there any behavioral health issues or concerns at this time?

IF YES, PLEASE EXPLAIN

Any special needs that we should be aware of?

IF YES, PLEASE EXPLAIN

Has your child ever been admitted to a hospital for a mental health condition?

IF YES, PLEASE EXPLAIN

JEFFERSON PARISH SCHOOL-BASED HEALTH CENTERS OVER THE COUNTER MEDICATIONS

The following over the counter medications* have been approved by the physician of the Health Center to be administered to your child by the Nurse if needed:

I agree that this student may receive all of the medications offered at the School-Based Health Center except those which I have written here:

Policy & Procedure Statement:

The Jefferson Parish School Based Health Center (SBHC) will require a completed consent/enrollment form to enroll a student for services at the SBHC. This complete consent and enrollment form will be good for the student as long as they are attending school within the same school district. The SBHC may ask the parent/legal guardian to complete an annual update form. All minor children, prior to receiving services, must have a current parent consent form on file, with the following exceptions: patients who are legally emancipated or anyone 18 or older. All parent consent forms remain part of the permanent medical record. Consent forms with questionable signatures may be rejected at the discretion of the SBHC staff. A parent or guardian is defined as either a natural or adoptive parent, in case of divorce, the parent with legal custody, or a non-custodial parent if the other is unavailable. If there is no court order, either parent can consent. Foster parents may give consent for their dependents but must produce a signed document from the natural parents or court. Stepparents, grandparents, and other relatives may not give consent unless they can produce a document showing that they have legal custody. This SBHC abides by Louisiana Law R.S. 37:1262 for the utilization of telehealth in the practice of healthcare delivery, diagnosis, consultation, treatment, and transfer of medical data using interactive technology.

I understand that the Office of Public Health (“OPH”), Adolescent School Health Program provides oversight to the SBHC and, as part of such a program; the SBHC is 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. I agree to the disclosure of SBHC information to the Office of Public Health, or its agent, in connection with the operation, funding, and ongoing monitoring of SBHCs.

Confidentiality: The SBHCs adhere to all current laws regarding the confidentiality of health services in general and specifically as they relate to services of minors. All medical and mental health records are confidential and will be maintained as directed by the Health Insurance Portability and Accountability Act (HIPAA). I consent to the exchange of relevant health information between this Jefferson Parish SBHC and the student’s personal medical provider upon referral for medical care. I may request a copy of the organization’s Notice of Privacy Practices that describes how health information is used and shared. I understand that Jefferson Parish SBHCs have the right to change this notice at any time. I may obtain a current copy by contacting the SBHC directly or calling 504-341.4006.

Louisiana Law R.S. 40:31.3 states that: Health centers in schools are prohibited from:(1) Counseling or advocating abortion in any way or referring any student to any organization for counseling or advocating abortion. (2) Distributing at any public school any contraceptive or abortifacient drug, device, or other 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

By signing this consent, you are agreeing for the SBHC to provide primary, comprehensive, and preventive healthcare, physical examinations, immunizations,(A seperate consent will be required and this does not include COVID vaccines), health screenings, laboratory/diagnostic testing, acute care for minor illness and injury including medications, if indicated, dental care (where available), management for chronic diseases, behavioral health services, health education, and prevention, case management, referral and follow-ups for emergencies, referral to specialty care, risk assessments, and telehealth services.

I, as a legal parent/guardian, understand that I will not be charged for any of the services provided at the SBHC. I also understand that Jefferson Parish SBHCs,InclusivCare or the medical provider may bill Medicaid or other insurance providers for these services. I authorize/ assign payments of authorized benefits directly to Jefferson Parish SBHCs and/or InclusivCare I understand that the SBHC is operated by Jefferson Parish Public School System and its employees and contractors, InclusivCare. My signature below acknowledges that I give permission for this student to receive the services provided by the SBHC. This consent is effective while the student is enrolled at a public school in this school district unless the SBHC is notified in writing that I no longer wish for the student to receive services

Printed Name of Parent/Legal Guardian (or Student over age 18)

Relationship to Student

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent/Legal Guardian (or Student over age 18)

Date:

Your information will be encrypted.