Collinsville School BH Consent Form English

  

 

School-Based Health Center  

Authorization to Treat a Minor Child

 

The SIHF Healthcare School-Based Program is a partnership with Collinsville Community Unit School District No. 10 (CCUSD) to provide primary healthcare services. By completing this form and consenting for services, you are granting permission for the evaluation and treatment of your child. In addition, you are granting permission for the release of necessary information by both SIHF Healthcare and CCUSD for the purpose of documenting compliance with state requirements and for the planning and delivery of quality healthcare (e.g. basic health history, immunization records, and school and sports physicals). 

By completing this form, you authorize insurance payment of medical benefits to SIHF Healthcare and the release of personal/health information necessary to process insurance claims.

This consent authorization will remain valid and on file with SIHF Healthcare and the School-Based Program as long as your child is enrolled in the CCUSD.  You reserve the right to revoke this authorization at any time.  

 

Consent for treatment:

I hereby consent to the enrollment of my child in the School-Based Program for the medical treatment encompassing routine diagnostic treatment and medical treatment by the medical staff or their designee as determined necessary in their judgment for the welfare of my child.   I understand that I may revoke this consent at any point by notifying SIHF Healthcare.    

I give permission for the following services:

__ Behavioral Health Examination

 

Parent/ Legal Guardian Authorization and Contact Information

Name: (print) ___________________________________________________________________

Phone (____) ________________________

Address__________________________________________________________________________

Signature_____________________________ Date _____/_____/_____

 

 

Child’s Name: _____________________________________DOB: ____/____/____

School’s Name_________________________________________________________________

 

Medical History

Allergies: (please list)

Medication/Drugs _________________________________________________________

 

Food ___________________________________________________________________

 

Other ___________________________________________________________________

 

Chronic Illness/Hospitalization or Surgery (please list)

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Health Insurance 

Medicaid Recipient ID# ____________________

Other Health Insurance

Plan Name________________________________ Policy Number__________________

Primary Subscriber________________________________ Group # _________________

 

Preferred Pharmacy

Name _____________________________________________________________

Location___________________________________________________________