September 7, 2017
Dear Parents/Guardians of middle & high school students attending Lewiston Public Schools:
We are thrilled to tell you that, due to the support of the Lewiston School District, we are able to provide School Based Health Center services again this school year! School Based Health Centers offer quality medical and mental health care to children and adolescents in school. Enrollment is FREE and open to all Lewiston middle and high school students. Enclosed are forms you must complete, sign and return so your child can access the services offered at the SBHC. Please return all signed forms to the Health Center.
Our program is separate from the school nurse and we work collaboratively. We are able to see your child for a visit at school no matter where they receive their primary medical care (CCS Pediatrics, B St. Health Center, CMMC, Pediatric Associates, St. Mary’s, etc.). We will contact your child’s primary care provider regarding any medical care that is provided at the SBHC. Our health centers offer:
First aid for minor accidents and injuries.
Vaccine administration.
Diagnosis and treatment of illnesses such as strep throat, mono and ear infections to include prescription medication, if needed.
Evaluation of recurring symptoms such as headaches or stomach pain.
Mental Health and Substance Abuse counseling services provided by an on-site licensed mental health professional.
Health Risk Assessments based on your child’s needs.
Assistance with chronic illnesses such as; asthma or diabetes.
Sports screens/physicals.
Reproductive health.
Routine lab tests including screenings for strep and anemia, urinalysis and PPD.
Education on wellness, nutrition and smoking cessation.
Please know that if your child sees our Nurse Practitioner or Licensed Mental Health Clinician, your insurance plan (MaineCare, Commercial Plan) will be billed according to the terms of your insurance. In addition, because we are also a Federally Qualified Health Center, you may be eligible to receive free services or services a reduced rate, if you qualify. Please let us know if you are uninsured and we will gladly provide you with information regarding the application process for FQHC coverage. Forms and information about the Lewiston School-Based Health Center are now conveniently located on our website:
Please feel free to call the SBHC’s if you have any further questions or concerns. We look forward to working with your child!
Sincerely,
Kristy Gelinas, Practice ManagerAshley Goodwin, Practice Manager
Outpatient Counseling ProgramCCS Pediatrics
207-755-3437207-777-8892
Parents/Guardian-Please complete all pages of this form to allow your child to use the School-Based Health Center. This is an optional service, in addition to the school nurse. We partner with your students’ primary care doctor (i.e. Pediatric Associates, CMMC Family Practice, CCS Pediatrics, etc.) to coordinate care, we do NOT replace them. There is no enrollment fee to participate in this service.
Is your student currently enrolled in the School Based Health Center? Please circle one: Yes No
**If Yes, please proceed to complete the form, if any changes have occurred since 2016-2017 enrollment. **If No, Proceed to completing the form)
Name:______Date of Birth:______Sex (circle one): M F
Address:______Primary phone:______
Check one: ___Lewiston High ___Lewiston Middle Grade:______
Where does your child receive medical care?______Date of Last Physical ___/___/___
Doctor/Provider’s Name:______
Emergency Contact Information:
Parent/ Guardian:______Phone: Home:______Work:______Cell:______
Name/ Relationship:______Phone: Home:______Work:______Cell:______
Email address:______
Medical/ Health Information:
The Health Centers work together with your child’s PCP or medical provider(s). So that we can work as a team to provide the best services, please list your child’s diagnosed medical conditions(eg: Asthma, Diabetes, etc.)
______
Does your child take medication(s) for any of these conditions? If so, please list name(s) & dose(s):
______
______
ALLERGIES: ______Type of Reaction: ______
Hospitalizations, significant past illnesses, injuries or surgeries:______
______
Depression or other mental health issues (anxiety, ADHD, etc.) ______
Would you like your child referred to a SBHC counselor for Mental Health or Substance Abuse Services (circle one)? Yes No
(Please note: if your adolescent already is seeing a counselor in the community, we cannot also provide care as insurance will only pay for one counselor at a time.)
2017-2018 Annual Update Form Page 2
Health Insurance Information:
Student’s Health Insurance Information MUST be completed: Student does NOT have insurance ______
Insurance Company: ______Policy # ______Group # ______
Insurance Address (on back of card): ______Insurance Phone # ______
Person who holds coverage (Subscribers Name):______DOB: / / SS #:______
Secondary Insurance Company: ______Policy # ______Group # ______
Insurance Address (on back of card): ______Insurance Phone # ______
Person who holds coverage (Subscribers Name):______DOB: / / SS #: ______
Consent for Treatment and Payment & Health Information Portability and Accountability Act :
* I authorize release of medical and related information, reportable communicable disease, and mental health recordsobtained in the course of diagnosis and treatment to my health insurance company or other third-party payer for the purpose of obtaining payment for service rendered. Authorization may be withdrawn at any time by written notification.
*I give permission for my childto receive medical/mental healthcare and education at the School-Based Health Center.
* As part of our services, we offer a health risk assessment assessing a student’s risk behaviors, as well as, overall medical and emotional well-being. If the student agrees to participate in the health risk assessment, the Nurse Practitioner or Counselor reviews this survey with the student face to face and provides education or counseling based on the answers provided. I agree to this service for my child.
* All services provided by the medical provider and/or counselor will be billed to the insurance company listed above. To avoid receiving a bill for services provided,it isimportant that you notify the health center of any changes to insurance coverage.
* I understand that the SBHC staff will share pertinent information with my student’s pediatrician/primary care provider to provide collaborative care(i.e. if medication is prescribed).
* I agree that my child may be photographed for marketing purposes.
* I hereby authorize the LewistonSchool Based Health Center Teaminvolved with my student’s care to disclose to, and/or obtain, health and education information/records from LewistonSchool Staffinvolved in educational servicesfor my student for the following purposes:
Educational evaluation and program planning.
Health assessment and planning for health care services and treatment in school.
Medical evaluation and treatment
Other: ______
The education information to be disclosed consists of:verbal conversations regarding educational planning, special education services (if applicable), and school performance/behavioral issues (if applicable).
The health information to be disclosed consists of: verbal conversations regarding care to be provided as it relates to the school setting.
Authorization: This authorization is valid for the duration of time that the student is enrolled with the Lewiston School System or until they transfer to another school (i.e. from middle school to high school). I acknowledge that when my student transfers from middle school to high school, I must re-enroll them in the health center if I would like for them to continue receiving services at the School Based Health Center. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that health records, once received by the school district, may not be protected by the Health Insurance Portability & Accountability Act (HIPAA), but will become education records protected by the Family Educational Rights and Privacy Act (FERPA). I have read this form completely and agree to enroll my student in the health center at this time.
Parent/Guardian Signature:______Date: ______
Please Print Name: ______Relationship to Child: ______
Patient/Student Signature*: ______Date: ______
* If a minor student is authorized to consent to health care without parental consent under federal or state law, only the student shall sign this authorization form. In Maine, a competent minor, depending on age, can consent to outpatientmental health care, alcohol and drug abuse treatment, testing for HIV/AIDS, sexual assault evaluation and reproductive health care service.
2017-2018Annual Update Form Page 3
Greater Lewiston/Auburn’s Federally Qualified Health Center
Affiliated with the St. Mary's Health System
Today’s DATE: ____/_____/201__ (updated 5/02/16)
PLEASE COMPLETE FOR YOUR STUDENT
ADDITIONAL INFORMATION VERIFICATION FORM
Community Clinical Services is a Federally Qualified Health Center (FQHC). We provide healthcare to people regardless of ability to pay. Because we are an FQHC, we are required to gather information on the patients we serve.PLEASE NOTE: YOUR PERSONAL INFORMATION IS CONFIDENTIAL. IT IS NOT DISCLOSED TO ANYONE, AND IS ONLY USED TO DEVELOP STATISTICS.
Student’s Last Name:______First Name:______M.I. ___Date of Birth: ______
- What is student’s preferred language? English Somali French Other:______
- Does student need an interpreter or sign language support? Yes No
- Race: White Black/African American American Indian or Alaska Native Asian
- Ethnicity: Hispanic/Latino Not-Hispanic/Latino
- Cultural Identity: American Somali Somali/Bantu Djoubtian Ethiopian Burundian
- Is your family/ the student Homeless? Yes No
Household Size and Income Verification
Please complete the following based on your household. You may qualify to receive a discount on your medical billing and may be eligible for free and/or low cost medications. Please ask us for a sliding fee scale application! Also, you may find the application online:
____Check here if your household income is “above” the grid below, for the household size, or if you choose not to tell us the amount.
My Household Size is… / 1 Person / 2 Persons / 3 Persons / 4 Persons / 5 Persons / 6 Persons / 7 Persons / 8+ Persons
Please Check The appropriate Box
My Household Income is
Below… / $24,120 / $32,480 / $40,840 / $49,200 / $57,560 / $65,920 / $74,280 / $82,640
Please Check the appropriate Box
****IMPORTANT**** Please complete all three pages of this form ****IMPORTANT****