Informed Consent - v.7.23

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:

• Mental Health Screening
• Mental Health Counseling
• Vision Screening
• Hearing Screening
• Physical Examination
• Clinical Laboratory Testing
• Immunizations

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:

• It can be easier and more efficient for you or your child(ren) to access health and wellness services.
• You or your child(ren) can obtain health and wellness services at times that are convenient for you or your child(ren) without the necessity of an in-office appointment, including follow-up care related to your or your child(ren)’s treatment.

Risks of Telehealth:

• Information transmitted to your or your child(ren)’s health professional (Provider) may not be sufficient to allow for appropriate health or wellness services to meet your or your child(ren)’s particular need.
• Some clinical needs may not be appropriate for a Telehealth visit.
• The technology necessary to interact with the health professional (Provider) may fail and delay service.
• Security protocols could fail, causing a breach of privacy of personal medical information.

Not for Emergencies:

• Telehealth services will not be used in a medical or psychiatric emergency.

In consenting to telehealth services, as indicated by my signature below, I understand the following:

1. The electronic nature of the Telehealth services means that there is a greater risk to the privacy of my or my child(ren)’s health information.
2. In some cases, my or my child(ren)’s Provider may be a nurse practitioner or physician assistant and not a physician.
3. Persons may be present during the Telehealth visit other than my or my child(ren)’s Provider in order to operate the Telehealth technologies and/or for language translation assistance, if requested.
4. Information pertaining to me or my child(ren) that is provided as part of any Telehealth offering will be treated as accurate, true, and complete. I understand that I or my child(ren) may have opportunities to correct any incorrect information.
5. In certain instances, and in compliance with applicable law, my or my child(ren)’s Provider may determine that it is appropriate to provide my or my child(ren)’s medical treatment asynchronously via store-and-forward technology. In such instances, my or my child(ren)’s Provider and I or my child(ren) may communicate electronically through an electronic platform and not via telephone or video.
6. When using an electronic platform, I or my child(ren) may not always be speaking or messaging with my or my child(ren)’s provider in real-time, and there may be a delay before my messages or information is reviewed.
7. I or my child(ren) must check the electronic platform for messages because this is the way that my or my child(ren)’s Provider will communicate important information to my child(ren) or me.
8. As is the case with all healthcare, Telehealth or not, there is no guarantee that I or my child(ren) will be provided medication. The decision of whether a prescription is appropriate will be made in the professional judgment of my or my child(ren)’s Provider.
9. While the use of Telehealth may provide benefits to me or my child(ren), no such benefits or specific results can be guaranteed, and my or my child(ren)’s condition may not improve.
10. There is a risk of technical failure during the Telehealth encounter beyond the control of the Provider using Telehealth.
11. The laws that protect the privacy and confidentiality of medical information also apply to medical information that derives from a Telehealth encounter.
12. I have the right to withhold or withdraw my consent to the use of Telehealth in the course of my or my child(ren)’s care at any time, without affecting my or my child(ren)’s right to future care or treatment.
13. A variety of alternative methods of medical care may be available to me or my child(ren), and I may choose one or more of these at any time. My or my child(ren)’s Provider has explained the alternatives to my satisfaction.
14. I have a right to receive a copy of this informed consent to Telehealth.

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:

• I have voluntarily chosen for myself or my child(ren) to receive vaccines;
• I am of legal age and authorized to execute this consent form;
• I will immediately alert the Provider of any medical conditions which may adversely affect my or my child(ren)’s personal health or effectiveness of the vaccine;
• I have been counseled about potential side effects after vaccination, when they may occur, and when and where I or my child(ren) should seek treatment. I am responsible for following up with my child(ren)’s physician at my expense if I or my child(ren) shall experience any side effects;
• I or my child(ren) should remain in the area for 15 minutes after the vaccination for observation;
• I have read, or have had read to me, the Vaccine Information Statement(s) (“VIS”) or Emergency Use Authorization (“EUA”) provided for the vaccine(s) to be administered to me or my child(ren);
• I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I understand the benefits and risks of the vaccine(s) to me or my child(ren).

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: