Introduction
Thank you for choosing Healthy Campus to coordinate your or your child(ren)’s school-based medical and behavioral health services. Our mission is to increase the health of the community by providing access to medical and behavioral health services on school campuses. This program is designed to benefit you or your child(ren) by providing medical and behavioral health services to you or your child(ren) in a high quality, time efficient, and cost-effective manner.
Healthy Campus offers school-based wellness programs that provide access to a wide range of services including wellness screenings, medical diagnostics, healthcare treatment, and behavioral health services to individual students and student groups onsite at school as well as via telehealth.
Healthy Campus works with health care professionals including without limitation professional medical groups, networks of employed and contracted licensed clinical health care providers, licensed pediatricians, nurse practitioners, physician’s assistants, nurses, behavioral health therapists, clinical laboratories and other ancillary service providers (each of which is referred to throughout this Informed Consent, for convenience, as “Provider”).
You or your child(ren) may contact Healthy Campus if you or your child(ren) have any questions or information to share about your or your child(ren)’s care for the Provider, and Healthy Campus will communicate the questions or information to the Provider.
Informed Consent to Wellness Services
I authorize Healthy Campus to arrange for “Wellness Services” (as defined below) to be rendered for me or my child(ren) by Provider. I authorize Provider to render Wellness Services for me or my child(ren). I understand that Wellness Services may include but are not limited to the following services:
If required by my health insurance plan, I will designate Provider as my or my child(ren)’s primary care provider for the specific Wellness Service rendered.
If you are signing on behalf of your child(ren) for Wellness Services to be rendered to your child(ren), please sign below:
I am the parent or legal guardian of the child(ren) named below. I have had the opportunity to discuss the Wellness Services with Provider or its designees, and all of my questions have been answered to my satisfaction. I hereby authorize and consent to the provision of Wellness Services including medical care deemed necessary by Provider, and its agents, associates or assistants. This authorization and consent shall be effective upon my signing and shall be effective, as to the child(ren) named below through the date the child(ren) shall graduate/matriculate from the school district (“District”) in which the child is currently enrolled.
Signed: | ||
By: | ||
Date: | ||
Child(ren)’s Name(s) | ||
If you are signing on your own behalf (for Wellness Services to be rendered to you), please sign below:
I have had the opportunity to discuss the Wellness Services with Provider or its designees, and all of my questions have been answered to my satisfaction. I hereby authorize and consent to the provision of Wellness Services including medical care deemed necessary by Provider, and its agents, associates or assistants. This authorization and consent shall be effective upon my signing and shall be effective through the later of – as applicable – the date my child(ren) shall graduate/matriculate from the District, or my last date of employment with the District.
Signed: | ||
By: | ||
Date: |
Informed Consent to Telehealth Services
Healthy Campus may arrange for certain Wellness Services (as earlier defined) to be provided via telehealth. Telehealth involves the delivery of such services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional (Provider) at one location and the patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. Telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters and interactive audio with store and forward.
Benefits of Telehealth:
Risks of Telehealth:
Not for Emergencies:
In consenting to telehealth services, as indicated by my signature below, I understand the following:
If you are signing on behalf of your child(ren)(for Telehealth to be rendered to your child(ren), please sign below:
I am the parent or legal guardian of the child(ren) named below. I have read and understand the information set forth above regarding Telehealth, I have had the opportunity to discuss it with my child(ren)’s Providers or designees, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telehealth in the delivery of medical care to my child(ren). This informed consent to Telehealth shall be effective upon my signing and shall be effective as to the child(ren) named below through the date the child(ren) shall graduate/matriculate from the District.
Signed: | ||
By: | ||
Date: | ||
Child(ren)’s Name(s) | ||
If you are signing on your own behalf (for Telehealth to be rendered to you), please sign below:
I have read and understand the information set forth above regarding Telehealth, I have had the opportunity to discuss it with my Providers or designees, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telehealth in the delivery of my medical care. This informed consent to Telehealth shall be effective upon my signing and shall be effective through the later of – as applicable – the date my child(ren) shall graduate/matriculate from the District, or my last date of employment with the District.
Signed: | ||
By: | ||
Date: |
Informed Consent to Vaccine Administration
I consent to the administration of vaccine(s) for me or my child(ren) by a medical professional arranged by Healthy Campus (“Provider”). I consent to be contacted at the telephone number I provided regarding other immunizations for which I or my child(ren) is/are due or eligible to receive. I also release Healthy Campus and Provider, and their affiliates, officers, directors, employees, and agents from all liability, including acts of omission or commission, resulting or arising from my child(ren)’s receipt of this vaccination.
In consenting to vaccine administration, as indicated by my signature below, I understand the following:
If you are signing on behalf of your child(ren) (for Wellness Services to be rendered to your child(ren), please sign below:
I am the parent or legal guardian of the child(ren) named below. I certify that I have read the foregoing and have been provided the opportunity to ask questions, and agree and accept all of the terms above on behalf of my child(ren). This informed consent to vaccine administration shall be effective upon my signing and shall be effective as to the child(ren) named below through the date the child(ren) shall graduate/matriculate from the District.
Signed: | ||
By: | ||
Date: | ||
Child(ren)’s Name(s) | ||
If you are signing on your own behalf (for Wellness Services to be rendered to you), please sign below:
I have had the opportunity to discuss the Wellness Services with Provider or its designees, and all of my questions have been answered to my satisfaction. I hereby authorize and consent to the provision of Wellness Services including medical care deemed necessary by Provider, and its agents, associates or assistants. This authorization and consent shall be effective upon my signing and shall be effective through the later of – as applicable – the date my child(ren) shall graduate/matriculate from the District, or my last date of employment with the District.
Signed: | ||
By: | ||
Date: |
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