School-Based Health Registration Form

APPLYING FOR THE BRH DISCOUNT SERVICES PROGRAM

If your child is uninsured at any time during the school year or you have a high insurance deductible plan, we would like to help by determining if you would qualify for discounted charges or our “sliding fee” which uses similar eligibility to the federal free and reduced lunch program. If you’d like to apply for this program, additional information must be completed to determine eligibility. Eligibility will be good for the entire school year.

1. I give consent for my child to receive any of the available services at a BRH School Health Center. BRH School Health Centers provide medical, dental, behavioral health, nutrition, and social work services to enrolled students who have completed registration, including written consent and signature of the parent or legal guardian. Staff of the BRH School Health Center will inform parents of significant findings and treatment recommendations for minor children, for conditions other than those exempted by state law. For your convenience and at your request, some services may be provided by telehealth. 2. I authorize the release of information to my child’s primary care provider, School Nurse, and the school’s Student Support Services any medical information pertinent to my child’s general health and care while they are at school. I authorize the release of information from my child’s primary care or behavioral health provider, School Nurse, and the school’s Student Support Services to the BRH School Health Center for coordination of care. 3. I authorize the release of any medical information, including information on communicable diseases, dental, behavioral health, and nutrition information necessary to process an insurance claim for payment of benefits to the BRH School Health Centers. 4. I authorize payment of insurance benefits for services rendered at the BRH School Health Centers, though Blue Ridge Community Health Services Inc. 5. I understand that Blue Ridge Community Health Services (BRH) operates the School Health Centers, and I must contact BRH to make special payment arrangements if I am unable to pay the bill in full. 6. I understand that all my child’s records will be strictly confidential, and maintained in compliance with state and federal laws, including HIPPA and any paper records will be maintained onsite at the BRH School Health Center facility. Information is only shared with those individuals you give permission to receive. 7. I confirm that all information given is complete and accurate.

Please sign the following declaration

By submitting this form, I authorize my child to receive all services available from the School Health Center. I understand that this consent is voluntary and is valid for the entire time that my child is enrolled in school. I understand that I may also revoke my consent, in writing, at any time. I understand that it is my responsibility to provide up-to-date information on the insurance coverage I carry on my child, including Medicaid and NC Health Choice. I also understand that I am financially responsible for all charges and any co-pays or deductible amount not covered by my insurance. I further understand I am responsible for understanding my own insurance plan and whether services are covered or require pre-authorization. If services require pre-authorization, I understand this is my responsibility.