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New London Local Schools, PSI and University Hospitals are excited to offer the School-Based Telehealth Program for students and staff! Please read through the following consent and authorization information and electronically provide your signature to enable eligibility for the program. 

Notice of Privacy Practices: Allows for the understanding of privacy policies within the University Hospital Health System 

General Consent for Treatment: Allows your child to receive treatment from University Hospitals 

Informed Consent for Treatment: Allows your child to receive medical care in the school through telemedicine 

Consent for Release of Education Records and Information: Allows the school to work with the healthcare team and allows the school to share medical, psychological and other personal information about your child with the healthcare provider. 

Authorization to Disclose Protected Health Information: Allows the health care team to work with the school and allows the healthcare providers to share medical, psychological, and other personal information about your child with the healthcare provider.

Authorization for Treatment 

I hereby represent that I am the legal guardian of student identified on this form, have the authority and do hereby, in addition to agreeing to the General Consent for Treatment, give my consent for my child, named above, to receive medical care from the School-Based TeleHealth Program provided by PSI (PSI) and University Hospitals (UH). Care will be provided in a private manner and information will not be released without my consent. I allow physicians or designated health professionals to provide necessary and/or advisable treatment for my child and to bill for this service in accordance with school policy. I understand that my child may receive medical care from providers, who are authorized by my child’s school district but who are otherwise not affiliated with New London Local Schools. 

This consent form authorizes UH and PSI to provide urgent care telemedicine services (“Services”) to the Patient named above. Those who provide the Services may not be physicians. Services may be provided by independent practitioners, including physicians. All of University Hospitals Health System, Inc. locations and providers are called UH in this form. UH is a teaching institution and healthcare personnel in training may be present and participate in providing care. UH is not responsible for the acts or omissions of providers who are not directly controlled by UH. As used in this form, Services are the diagnostic, therapeutic, medical, physician, nursing, technical, and/or surgical services and/or procedures and associated support, including, but not limited to, x-rays, photographs, and laboratory testing necessary for care and quality assurance. Services will be provided through telehealth, utilizing technology to connect me and/or data about me to providers who may not be in the same physical location. There are potential benefits and risks of the use of telephone or video-conferencing that differ from in-person services (e.g., limits to patient confidentiality, limitations on the service provider’s ability to observe the patient, limitations on the diagnostic tools available). You and/or the provider may determine at any point that telehealth services are not appropriate based on your child’s circumstances and either party may therefore end the Service to alternative in-person services or contact 911 to address a medical emergency. With the understanding of these risks, benefits and alternatives, you agree to use the telephone or video-conferencing platform selected for our virtual sessions and further understand that the Services do not guarantee a specific outcome or recovery. 

Authorization to Access & Release Information 

The purpose of the disclosure is: participation in school-based telehealth services. 

All healthcare information is private. By signing this form, you are giving the school clinic, the school health staff, and the student’s main health care provider consent to speak with and share medical information about the student’s health with UH as needed. This information will be treated in a confidential way. Examples of protected health information that may be shared include but are not limited to medical history (including any medical diagnosis and treatment), physical examinations, consults, lab reports, and a list of current medications. I acknowledge receipt of the University Hospitals Notice of Privacy Practices, which describes how UH may access and/ or release all or any part of Patient information (including, but not limited to, information regarding substance abuse, HIV testing, AIDS and psychiatric treatment) for purposes required by State and/or Federal law; in cooperation with a law enforcement investigation; treatment, billing or collecting payment for Services, and/or health care operations, which include improving quality, accreditation, training and education, performance improvement initiatives, discharge planning, risk management, for research-related purposes, population health, including improvement of healthcare delivery and communications, participation in health information exchange(s), including Clinisync, patient registries, organ procurement organizations and clinical collaborations, or as otherwise authorized and for any other permissible purpose. UH retains patient medical records in accordance with applicable law. UH may, unless otherwise refused, photograph and/or audio or video record me or the Services I receive, including those in which I am identifiable. UH will own such images or recordings and may use them for any lawful purpose. 

I release UH, PSI and New London Local Schools from any liability that might result from the disclosure of this information. I may revoke this permission at any time. 

Consent for Release of Education Records and Information 

New London Local Schools shall obtain written consent before disclosing any personally identifiable information from an education record. I understand that the District will operate under the guidelines of the Family Educational Rights and Privacy Act (FERPA), state statutes and regulations, and state and District policies and procedures to ensure confidentiality regarding the release of student information. No information will be released or secured without prior approval from the parent, except as provided by law. 

New London Local Schools has my permission to release and exchange medical, psychological, and other personally identifiable confidential information, as necessary, to representatives of the School-Based Health program. I understand that the purpose of this consent is to refer my child for health-related services and treatment. 

Consent to Release Confidential Information 

By providing my signature below, I understand that granting consent for the release of personally identifiable information from my child’s education records is voluntary and may be revoked at any time. If I later revoke consent, that revocation is not retroactive (i.e., it does not negate an action that has occurred after the consent was given and before the consent was revoked). I understand this consent form is valid until I revoke it. 

By providing my signature below, I understand the recipient of these records must obtain my written consent before it can further share my child’s information from the District with any other party, such as for the purpose of billing Medicaid or commercial insurances. If I provide written consent for the service provider to share my child’s information with another party, the re-disclosure of my child’s information by the recipient may no longer be protected by the requirements of the Family Educational Rights Act (FERPA). This consent remains effective until written notification is received. 

I understand this consent form is valid, until I revoke it. 

By signing below, I, as or on behalf of the Patient, consent to receive and authorize UH to provide the Services. 

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Minor
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First Parent/Guardian Name

First Name*

Last Name*
First Parent/Guardian Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian Signature*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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