New York City Department of Education Oral Health Clinic Program

Page 1 of 2

New York City Department of Education Oral Health Clinic Program - School Parental Consent Form

__________________________

First MedCare Pri

___________

mary Care Center

__________________________________________________ (OHCP)

______________________

8707 Flatlands Avenue,

__________________

___

rooklyn, N

________

Y 11236

_____________________________ (OHCP Address)

STUDENT INFORMATION

Student’s Last Name: _______________________________

Student’s First Name: _______________________________

Date of Birth: ___________ / __________ / ___________

Month Day Year

Student Address: ______________________________________

______________________________________

City State Zip Code

School: ________________________________Grade: ___________

Teacher’s Name: _______________________________________

IMPORTANT MEDICAL QUESTION

Does your child have any medical condition that may affect or

complicate dental treatment? This may include heart, breathing

or bleeding issues, seizures, allergies, communicable diseases,

immune disorders, etc. If Yes, explain. IF NO, LEAVE BLANK

______________________________________________________

PARENT/GUARDIAN INFORMATION

Mother

Last Nam e: First Nam e: _____________

Father

Last Name: First Nam e: _____________

Legal Guardian, If Applicable

Last Name: First Nam e: _____________

Relationship of legal guardian to student

Grandparent  Aunt or Uncle  Other:

Contact Information for parent or guardian

Home Tel: _________________ Work Tel: _______________

Cell: _____________________________________________

Email: _____________________________________________

Additional Emergency Contact

Name: _____________________________________________

Relationship to Student:________________________________

Home Tel: __________________ Work Tel: _______________

Cell: _____________________________________________

Email: _____________________________________________

INSURANCE INFORMATION

Does your child have Medicaid?



Yes: Medicaid ID #

____________________________

Does your child have Child Health Plus?

 No

 Yes: CHP # __________________________________

Which Plan?



Affinity



 Healthfirst

 HIP

 WellCare

 MVP

Fidelis

 Health Plus Amerigroup

 MetroPlus

 United Healthcare

 Empire BlueCross BlueShield

 Other: ______________________________________________

Does your child have coverage through an employer based

plan or other type of health insurance?

 No 

Yes, Health Plan:

___________________________

ember ID or Social Security Number:

____________________

Health Insurance Phone: _______________________________

Name of Insured Adult:

________________________________

Birth Date of Insured Adult: _____________________________

Services will be provided to your child regardless of whether or

not your child has health insurance, at no cost.

PARENTAL CONSENT FOR SCHOOL-BASED HEALTH CLINIC SERVICES

understand

that my child will be receiving oral health services

and

signature

provides

consent for

child

receive

services

provided

the

OHCP

for

long

child

enrolled

school.

may

withdraw

consent

any

time

written

notice

the OHCP

. I understand that

I will report any significant changes in my child’s health to the provider.

NOTE:

law,

parental

consent

not

required

for

students

who

are

years

older

for

students

who

are

parents

legally

emancipated.

signature

indicates

have

received

copy

the

Notice

Privacy

Practices.

X_________________________________________________________ ____________________

Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law) Date

HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION

I have read and understand the release of health information on page 2 of this form. My signature indicates my consent to release

health information as specified

X___________________________________________________

________ ____________________

Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law) Date

Page 2 of 2

New York City Department of Education Oral Health Clinic Program - School Parental Consent Form

___________________________________________________________________

First MedCare Primary Care Center

____________________ (OHCP)

__________________________________________________________________

8707 Flatlands Avenue, Brooklyn, NY 11236

______________ (OHCP Address)

CONSENT FOR SCHOOL-BASED ORAL HEALTH CLINIC SERVICES

I consent for my child to receive oral health care services provided by the State-licensed health professionals of the OHCP as part

of the school oral health program approved by the New York State Department of Health for as long as my child is enrolled at school.

I may withdraw my consent at any time by written notice to the OHCP. I understand that confidentiality between the student and the

oral health clinic provider will be ensured for specific service areas in accordance with the law, and that students will be encouraged

to involve their parents/guardians in counseling and oral care decisions. School-Based Oral Health Clinic Services may include, but

are not limited to, preventative oral health services, restorative services, and emergency procedures. Preventative oral health

services include, but are not limited to, comprehensive dental exams, dental hygiene treatments, x-rays, sealants and fluoride

treatments. This may also include the application of Silver Diamine Fluoride on back teeth to halt the progression of cavities (Silver

Diamine Fluoride may discolor any cavities resulting in a brown or black color). For services other than comprehensive dental exams

and preventative oral health services, the OHCP shall notify the parent/guardian of the services and treatments to be provided

including fillings, extractions, and the use of anesthetics or other medications. If the parent/guardian does not consent, these

services shall not be performed.

HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION

My signature on the reverse side of this form authorizes the release of health information. This information may be protected

from disclosure by federal privacy law and state law.

By signing this consent, I am authorizing health information to be released to the Board of Education of the City of New York

(a/k/a New York City Department of Education), which may include school nurses, because it is required by law, Chancellor’s

regulation, because it is necessary to protect the health and safety of the student, or in order to process a claim with my

child’s insurance provider. Upon my request, the facility or person disclosing this health information must provide me with

a copy of this form.

Parents are required by law to provide certain information to the school, like proof of immunization.

Failure to provide this

information may result in the student being excluded from school.

My questions about this form have been answered. I understand that I do not have to allow the release of my child’s health

information, and that I can change my mind at any time and revoke my authorization by writing to the OHCP

. However, after

a disclosure has been made, it cannot be revoked retroactively to cover information released prior to the revocation.

I authorize

the OHCP to release specific health information on the student named on the reverse page to the Board of

Education of the City of New York (a/k/a New York City Department of Education).

I consent to the release from the OHCP

to the NYC Department of Education and from the NYC Department of

Education to the OHCP

, of health information outlined below in order to meet regulatory requirements and to ensure

that the school has information needed to protect my child’s health and safety. I understand that this information

will remain confidential in accordance with Federal and State law and Chancellor’s Regulations on confidentiality:

- Conditions which may require emergency

- Conditions which limit a student’s daily activity (Form 103S)

- Diagnosis of certain communicable diseases (not including HIV infection/STI and

other c

onfidential services protected by law).

- Health insurance coverage

My signature on page 1 of this form also gives my consent to the OHCP

to contact other providers that have

examined my child and to obtain insurance information.

The Release of Information is authorized from the date that form is signed until the student is no longer enrolled in the School

Based Oral Health Clinic Program or until revoked, whichever is earlier.

Patient Rights and Privacy Policy shall be provided by the OHCP, as applicable by law.

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