School Based Consent Form

Select School District**
Student Information
First Name**
Middle Name**
Last Name**
Gender**

MaleFemale
Date of Birth*

MonthDayYear
Date
Social Security #
Street Address**
Address Line 2
City**
State / Province / Region**
ZIP / Postal Code**
Country**
Email**
Race/Ethnicity
Race/Ethnicity (Select all that apply)*

White/CaucasianAfrican American/BlackHispanic/WhiteAsianNative HawaiianAmerican IndianOther Pacific Islander
Please mark all that apply to the patient**

VeteranLive in Public HousingHomelessMigrantNone
Parent/ Guardian Information
Parent/ Primary Guardian (1)*
Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Parent/ Guardian (2)*
Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Emergency Contacts
Emergency Contact (1)*
Phone Number*

Area CodePhone Number
Relationship*
Emergency Contact (2)
Phone Number*

Area CodePhone Number
Relationship
Authorized Persons

**Please list below anyone other than the above named parent or legal guardian who is authorized to bring your child into the clinic for services, or that may give verbal consent to treat. All persons listed below must be 18 or older. This authorization includes examination, necessary blood work, diagnostic imaging, as well as the administration of any recommended immunizations. This authorization will remain in effect unless otherwise notified in writing.
Authorized person (1)
Relationship to child
Date of Birth

MonthDayYear
Date
Authorized person (2)
Relationship to child
Date of Birth

MonthDayYear
Date
Medical Insurance Information
Medical insurance:*

UninsuredMedicaid/ARKidsPrivate/Commercial
Guarantor's Name
Relationship to student
Date of Birth

MonthDayYear
Date
Policy number
Group number
Responsible party for any billing payments
Address
Dental Insurance Information
Dental insurance:

UninsuredMedicaid/ARKidsPrivate Insurance
Guarantor's Name
Relationship
Date of Birth

MonthDayYear
Date
Policy number
Group number
Primary Care Provider Info
Student's Primary Care Provider/Physician
Student's Dental Home Provider
Preferred Pharmacy
Medical and Family History
Asthma:

StudentMotherFatherGrandparentsSister/Brother
Anemia:

StudentMotherFatherGrandparentsSister/Brother
Allergies:

StudentMotherFatherGrandparentsSister/Brother
Birth Defects:

StudentMotherFatherGrandparentsSister/Brother
Behavioral Concerns:

StudentMotherFatherGrandparentsSister/Brother
Cancer/Tumor:

StudentMotherFatherGrandparentsSister/Brother
Chickenpox:

StudentMotherFatherGrandparentsSister/Brother
Diabetes:

StudentMotherFatherGrandparentsSister/Brother
Depression:

StudentMotherFatherGrandparentsSister/Brother
High Blood Pressure:

StudentMotherFatherGrandparentsSister/Brother
Heart Attack/Disease:

StudentMotherFatherGrandparentsSister/Brother
Kidney Disease:

StudentMotherFatherGrandparentsSister/Brother
Sickle Cell:

StudentMotherFatherGrandparentsSister/Brother
Seizures:

StudentMotherFatherGrandparentsSister/Brother
Stroke:

StudentMotherFatherGrandparentsSister/Brother
Whooping Cough:

StudentMotherFatherGrandparentsSister/Brother
Liver Disease:

StudentMotherFatherGrandparentsSister/Brother
Skin Conditions:

StudentMotherFatherGrandparentsSister/Brother
Stomach Problems:

StudentMotherFatherGrandparentsSister/Brother
Mental Illness:

StudentMotherFatherGrandparentsSister/Brother
Allergies (including food, pollen, odors, medicines, pets, etc):*

StudentMotherFatherGrandparentsSister/BrotherNone
Please list allergies if applicable:
Current Medications (including vitamins/OTC/supplements), Please specify 'dose' and 'times/day':**
Previous Hospitalizations:*

YesNo
Previous Hospitalizations:

YesNo
If yes, please list specific information below: (Reason, Location and Month/Year)
Please list any other medical problems that your child has that we need to know about:*
Has your child had dental care in the past 12 months?*

YesNo
Does your child have an appointment scheduled at the dental home where dental care is normally provided?*

YesNo
If YES, please list the name and address of the dentist or dental home where the care was provided:
How often does your child brush?
Does your child floss?

YesNo
If yes, how often?
Any specific concerns you have regarding the child's teeth?
Household Information
Number of Household Dependents:
Gross Household Income: $
Does the student receive free or reduce lunch?**

YesNo
In an effort to ensure that payment of fees is not a barrier to care, Mainline Health Systems, Inc. offers those who need it a waiver of fees. All waiver requests will be specific to location and services approved, and are granted at Mainline's discretion.

YES, I request a waiver of fees.NO, I do not request a waiver of fees. I understand all services may be billed directly to me including co-pays and deductibles for services rendered.
I understand that the School Based Health Center can provide health services to my child. One consent form per child must be signed and on file in order for the student to receive services.

Available services may include: Covid19 testing, physical exams, well child visits, routine lab work, and evaluation of injuries, vaccinations, chronic disease management, dental x-rays, dental cleanings, dental sealants, fluoride treatments, behavior assessments, medication management, and individualized therapy. Available services may vary by school district.

Services will only be offered as appropriate, if available, and if consent is given. Verbal consent will be obtained PRIOR to each visit.

By signing below, I hereby voluntarily consent to outpatient care encompassing routine diagnostic procedures, examination, and medical treatment, including but not limited to, routine laboratory work (such as blood, urine and other studies), and administration of medications prescribed by the provider. I further consent to dental services (if available and requested), including but not limited to, taking of dental x-rays, routine cleaning, dental sealants, and fluoride treatment. I further consent to behavioral health services (if available and requested), including but not limited to, behavior assessments, medication management, and individualized therapy. I further consent to the performance of those diagnostic procedures, examinations and rendering of treatment by the medical, dental, and/or behavioral health staff, including nurses, dental hygienists, and/or social workers, as is necessary per provider judgment.

Regarding release of information: (a) I authorize the clinic to release medical, dental, and/or behavioral health information to the third party insurance carriers for the purposes of filing insurance claims related to my (his/her) care. (b) I further authorize the release of all health information about treatment here to my (his/her) doctor or any designated by me for continuity of care. (c) I further authorize the ability to view prescriptive history from external sources. (d) I further authorize the release of health information to federal and state governing entities for the purposes of required reporting. (e) I further authorize the exchange of health information to the school as needed for continuity of care and required reporting.

I agree that my insurance company, if I have coverage, can be billed for services rendered, and that any remaining co-pays, deductibles, and/or coinsurance may be billed to me directly. I agree that any services provided but processed by a third party contractor (Lab Corp) such as routine laboratory work (including but not limited to blood, urine, and/or swabs) must be billed to me directly. I further understand that no person is turned away due to inability to pay.

I understand that the Notice of Privacy Practices document has been provided to me.
I consent for my child to receive the following service(s) through the School Based Health Center.

MedicalDentalBehavioral Health
COLLABORATIVE CARE DENTAL HYGIENISTS:

Hillary Montgomery, RDH license #1950

Sandin Rhodes, RDH license #2508

Layne James, RDH license #2385

COLLABORATIVE CARE CONSULTING DENTISTS:

Skylar Garner, DDS license #4185

Terry Eubanks, DDS license # 2854
By selecting yes below I comfirm that I understand that I can choose to have dental hygiene services in a public setting provided at the dental home where care is normally provided rather than a public setting. I understand that all dental hygiene care provided by the dental home I have used in the past or a collaborative care dental hygienist will reduce future benefits that the child may receive from private insurance, Medicaid (ARKIDS) or other third party provider of dental hygiene benefits for the remaining benefit period.”

Yes
Would you like Mainline Health Systems to contact you to set up an appointment with a dental hygienist or dentist for your child.

Yes
Contact Name (Dental Appointment)

First NameLast Name
Contact Phone (Dental Appointment)
Please enter a valid phone number.
Emergency Transportation

YES! I consent that my child may be transported bythe school district during an emergency if the parent or additional emergencycontacts listed on file cannot be reached.NO! I do not consent that my child may betransported by the school district during an emergency if the parent oradditional emergency contacts listed on file cannot be reached.
Primary Care Provider Referral Agreement

In order for Mainline Health Systems, Inc. to receive reimbursement from Medicaid and certain commercial insurances, a referral from the current PCP is required. However, if a referral cannot be received from the PCP, the parent also has the option to change the student’s PCP to Mainline Health Systems, Inc. Mainline will always give referrals in the event the child needs care outside of Mainline Health Systems, Inc.
Signature*

Clear
Relationship**
If you are needing to complete a consent for a scheduled dental procedure please select "Dental Procedure Consent Only". You will be redirected to the form. Otherwise leave blank.

Dental Procedure Required
Should be Empty:

Student Information

Parent/ Guardian Information

Emergency Contacts

Authorized Persons

Medical Insurance Information

Dental Insurance Information

Primary Care Provider Info

Medical and Family History

Household Information