NORTHEAST VALLEY HEALTH CORPORATION

San Fernando High School Health Clinic

11133 O’Melveny Street, San Fernando, CA 91340

(818) 366-7517

PARENT/LEGAL GUARDIAN CONSENT FORM

NAME OF STUDENT: GRADE TRACK

ADDRESS

HOME PHONE

BIRTHDATE SOCIAL SECURITY NUMBER

PARENT/LEGAL GUARDIAN EMERGENCY OR WORK PHONE NUMBER:

I/We have read and understand the services offered at the School Teen Health Center as described below: I/We understand further that the services authorized by my/our signature on this form are simple, common or routine health care services, and treatment will be limited to:

1.  Diagnosis and treatment of minor and acute illnesses 10. Vision and hearing screening.

2.  First aid for minor injuries 11. Laboratory services

3.  Physical examinations (general, sports, pre-employment) 12. Limited x-ray services at Northeast Valley Health Corporation

4.  Assistance with chronic (ongoing) illnesses, such as, asthma, diabetes and epilepsy Health Centers

5.  Treatment of acne and other skin problems 13. Prescriptive and over-the-counter items, including psychiatric medicine

6.  Diagnosis and treatment of sexually transmitted diseases 14. Diet and weight control programs

7.  Family planning services, including examinations and contraceptive methods 15. Alcohol and other drug abuse counseling and referral

8.  Pregnancy testing and referral for prenatal care 16. Psychological Services

9.  Immunizations 17. Referrals for health care services which cannot be provided at teen

Health Center

18.  HIV testing and counseling

I/We understand that this consent covers only those services provided at this clinic or another Northeast Valley Health Corporation Clinic which is a result of a referral made by the Teen Health Center, and does not authorize services rendered at any other private or public facility.

I/we hereby authorize a physician and other professional clinic staff to provide necessary and/or advisable treatment for my son/daughter. This student has my/our permission to receive all services offered at the School Teen Health Center EXCEPT those which I have specifically excluded above.

I/WE UNDERSTAND THAT NO STUDENT OR HIS/HER FAMILY WILL BE CHARGED DIRECTLY FOR SERVICES. All third party payment sources will be billed. Grant funds will be used to support services rendered to students without insurance or Medi-Cal.

Medical Records will be kept in a confidential manner, however I/We acknowledge that the Teen Health Center may release information regarding treatment to third-party payers such as Medi-Cal or insurance companies for the purpose of billing. I/we also understand that public information such as immunization history or illness of a public health hazard may be shared with the school nurse to protect the health of other students, or the public health of other students, or the public health department to protect the health of the public in accordance with the California Health and Safety Code.

Signature of Parent/Legal Guardian Date

Relationship to student:

Signature of student Date

Address of parent or legal guardian if different from above

Telephone

Signature verified by (OFFICE USE ONLY) Date


INSURANCE INFORMATION

While no charge will be made directly to you for any health services provided on school premises, the Health Center is permitted to recover for such services from third party payors. Therefore, we ask that you supply the Medi-Cal and insurance information requested.

Medi-Cal/Medicaid # (if applicable)

Other Health Insurance

Name of Insured

Relationship to Student

Social Security Number of Insured