Healthcare School Packet

HEALTHCARE SCHOOL PACKET

STUDENT / PATIENT INFORMATION

Student Name:

Date of Birth:

Gender: Male Female Other Prefer not to answer

EMERGENCY CONTACT

SCHOOL / ACADEMIC INFORMATION

INSURANCE / BILLING INFORMATION

Subscriber Date of Birth:

MEDICAL HISTORY

Provide details below. If none, write "None."

Immunizations up to date: Yes No If no, provide details below.

MEDICATION ADMINISTRATION AT SCHOOL

I authorize the school nurse or designated school personnel to administer medication to the student as prescribed by a licensed prescriber and according to written instructions provided to the school. I understand medication must be delivered in original labeled container with instructions.

Permission to administer medication at school: Yes No

CONSENT FOR EMERGENCY TREATMENT & TRANSPORT

In the event of an illness or injury requiring immediate medical attention, I authorize school personnel to secure emergency medical services for the student, including transportation to a hospital or other medical facility. I authorize the release of pertinent medical information to emergency responders and treating medical personnel. I understand the school will attempt to notify the emergency contact listed above as soon as reasonably possible.

Consent to emergency treatment: Yes No

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (HIPAA AUTHORIZATION)

I authorize any treating health care provider to disclose the student’s medical records and information to the school nurse, school administrators, designated school staff, and the student’s insurer for purposes of treatment, coordination of care, and billing. This authorization includes immunization records, medication orders, allergy information, and limited diagnostic test results necessary for the school to provide health services.

This authorization is valid until: . I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken based on this authorization.

Acknowledgement of privacy practices: I acknowledge that I have been provided information regarding the school's privacy practices and understand how my child's health information will be used and disclosed for school health purposes.

PARENT/GUARDIAN CERTIFICATION

I certify that the information provided in this packet is true and correct to the best of my knowledge. I authorize school health staff to consult with the student's health care providers as necessary to coordinate care. I accept financial responsibility for services rendered by external medical providers if not covered by insurance or if authorization is required and not obtained.

Parent/Guardian certifies: Information is accurate and authorization is granted as indicated above.

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