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South Hagerstown High School Online Enrollment

Parental Consent for Enrollment

I am granting permission for my child to enroll in the School-Based Health Center and consent to his/her receiving health related services which may include physical examinations, health screenings, limited diagnostic tests (e.g., throat culture), education, counseling, referrals, and administration of necessary medications. You have my permission to obtain/release any Health Center information to/from my child’s health care provider, MCO, Mental Health Provider, School Health Staff, and the schools’ staff when needed to coordinate care.

  • I understand that services are confidential except in life threatening situations or emergency services in accordance with Maryland law.
  • I understand that the School-Based Health Center program can supplement the care provided by my private medical provider as long as my child attends Western Heights Middle School or South Hagerstown High School.
  • I understand that I am responsible for medical care if follow-up outside the school-based center is recommended.
  • I understand that if my child is registered with Medical Assistance, he/she can still receive treatment at the school health center. No student will be denied access to health care services due to inability to pay.
  • I understand that Maryland Law allows a minor to receive treatment and/or advice about sexually transmitted disease, pregnancy, contraception, sexual offenses and drug or alcohol abuse without further parental consent.
  • I understand that Maryland Law allows a minor of 16 years of age or older to receive treatment and/or advice about mental health without further parental consent.
  • Please note: staff encourage every student to involve his/her parent or legal guardian in health care decisions.
  • I understand that if guardianship changes, a new consent form must be signed by the legal guardian.
  • I understand that by providing an alternate contact, if I cannot be reached, medical information regarding the above named student will be shared with the medical provider and the alternate contact.
“This form may only be completed by a parent as listed on the student’s birth certificate on file with Washington County Public Schools or the student’s legal guardian as identified in official court documents.
Child's Name
Birth Date
Race Grade
Gender
Address Apt #
City State Zip Code
Child's Social Security Number
--
Child's Phone
--
Child's Doctor
Parent's Phone Home
--
Work
--
Cell
--

Parent Information

School-Based Health Center (SBHC) staff is often asked to participate in school team meetings regarding students who are enrolled in the SBHC, as well as share information regarding those students. Compliance with HIPAA regulations must be followed. In addition, the following must be followed regarding sharing of this information:

  • Parents/Guardians must be informed that SBHC staff will be attending a school meeting on their child’s behalf. This notification/permission to attend must be documented. If SBHC teams regularly attend school meetings, the FERPA required annual parental notification of parent’s rights must include SBHC as those professionals that may be attending school meetings on individualized students.
  • Immunization information may be shared with school personnel, parents/guardians, and other health providers without written consent.
  • Communication between SBHC healthcare practitioners and school nurses regarding treatment orders can take place without parental permission according to HIPPA and the Maryland Nurses Practice Act.
  • SBHC staff must obtain parental permission to obtain school health services records (with the exception of immunization records) and vice versa.
  • If a student has a primary care provider, the SBHC must make every effort to communicate/coordinate services with the student’s primary care provider to avoid duplication of services.

My signature below also acknowledges that I have received a copy of Meritus Health School- Based Health Center Notice of Privacy Practices. Unless I choose to withdraw my child in writing, this authorization will continue for the entire period of time the student is enrolled in Meritus Health School-Based Health Center/ Washington County Public Schools. Yearly updates will be requested of student’s health information.

Signature of Parent/Legal Guardian
Date
Relationship to Student

Medical Information Contact Instructions

Please Initial
I give Meritus Health School-Based Health Center staff permission to call my contact numbers with health care information.
I give the Meritus Health School-Based Health Center staff permission to leave a message with health care information on an answering machine or with a person at my home.
I give Meritus Health School-Based Health Center staff permission to mail health care information to my house.
I request to receive communications from Meritus Health School-Based Health Center as follows:

Confidential Student Health History

Where do you usually take your child for medical care?

Name Phone
--
Address
When was the last time your child had a well-child health assessment?
/

Where do you usually take your child for dental care?

Name Phone
--
Address
Last Dental Visit
/
Does your child use fluoride tooth paste?
Does your child have dental cavities?
What is the source of drinking water? Check all that apply.

Assessment of Student Health

To the best of your knowledge, does your child have a history of or any issues with the following?

Does your child have a physical disability?
If yes, please explain.
Does your child have a behavioral or emotional issue?
If yes, please explain.
Is your child currently under the care of a behavioral counselor?
If yes, please explain.
Does your child have a learning disability?
If yes, please explain.
Hospitalization over night within the last year?
If yes, please explain.
Concussion (Head Injury)?
If yes, please explain.
Surgery within the last year?
If yes, please explain.
Lead Poisoning?
If yes, please explain.
Issues with vision?
If yes, please explain.
Diet/Eating Issues?
If yes, please explain.
Unusual changes in weight?(i.e. Losing or gaining 10 or more pounds in a short time period)
If yes, please explain.
Diabetes?
If yes, please explain.
Ear Issues?
If yes, please explain.
Speech Issues?
If yes, please explain.
Heart Issues?
If yes, please explain.
Allergies? (Food, insects, medications?)
If yes, please explain.
Asthma?
If yes, please explain.
Sickle Cell Disease?
If yes, please explain.
Seizures?
If yes, please explain.
Bleeding Issues?
If yes, please explain.
Limits on Activity?
If yes, please explain.
Issues with Bladder/Bowels?
If yes, please explain.
Receives Annual Flu Vaccine?
If yes, please explain.
Is your child under the care of any medical specialist?
If yes, please explain.
Do you feel your child has any other health problem not mentioned above?
If yes, please explain.
Any social or peer issues?
If yes, please explain.
Does your child smoke?
If yes, please explain.
Any alcohol or drug use?
If yes, please explain.

Family History

Any sudden death of a relative? (Less than 50 years old)
If yes, please explain.
Immediate family members with heart disease, high cholesterol and/or diabetes?
If yes, please explain.
Other family medical issues not addressed above?
If yes, please explain.
Other family issues not addressed above?
If yes, please explain.
Does your child take any medications?(Include any herbal or vitamin supplements)
If yes, please list below.
Medication Dosage
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11116 Medical Campus Road
Hagerstown, MD 21742
301-790-8000
TDD: 1-800-735-2258
meritus Health
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