Western Heights Middle 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 may be shared by the medicalstaff with the alternate contact.

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 health care 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.

Western Heights Middle School