School-Based Health Center Forms

Permission Form
Parent Permission Form

Mountain Community Health Partnership
Students must have their parent’s permission to receive services through the School-Based Health Centers. Signing this Parent Permission Form will enroll your child in the Health Centers for the duration of time that they
are enrolled as a student in middle school. If at any time you choose for your child to no longer be enrolled in the Health Center, please contact us by phone. If you would like your child to be able to receive medical care while at
school, please do the following:
1. Sign and complete the parent permission form and student information
2. Complete the medical history form
3. Complete the Medication List
4. Complete the financial form, attaching a copy of all insurance cards

By signing this form, I consent to my student (child) having access to all available SBHC services: diagnosis and treatment of acute medical concerns or injuries, laboratory testing, health screenings and education, nutrition counseling, behavioral health services, and referrals as needed. Students must have parental/guardian permission to be seen at the School-Based Health Center.
Federal law requires that we notify you of the ways we may share health information. We are required to provide you with the Notice of Privacy Practices. The Notice of Privacy Practices is available in the School-Based Health Center. You may request a printed copy from any MCHP team member.

By signing below, you are acknowledging the following statements:
I have been offered a copy of the Notice of Privacy Practices.
I have read the enclosed information and give permission for my child to receive services from the School-Based Health Center.
I agree that the School-Based Health Center may share medical records information with the child’s physician and school system as necessary.
I agree for my insurance to be billed for services/treatment provided to my child in the School-Based Health Center.
Signature of Parent/Guardian/Conservator*

Clear
Date*

MonthDayYear
Date
Photo/Social Media Informed Consent

Mountain Community Health Partnership
Mountain Community Health Partnership participates in social media outlets such as Facebook, Instagram, The Mitchell News Journal, and/or any other local newspaper. With your permission, we would like to share pictures of this event.*

I give permission for Mountain Community Health Partnership to use and/or publish photos of me or my child in the local newspaper and on their social media platform.I do not give permission for Mountain Community Health Partnership to use and/or publish photos of me or my child in the local newspaper or their social media platform.
Signature of Parent/Guardian/Conservator*

Clear
Date*

MonthDayYear
Date

Insurance Verification Form
Insurance Verification Information

Please note: this form is required for all students being seen at the school-based health center
Please select the type of insurance:*

MedicaidHealth ChoiceBlue Cross Blue Shield (Any Blue Cross Blue Shield plans)CignaMedcostUnited HealthcareAetnaUninsuredOther
Insurance Subscriber Name

First NameLast Name
Subscriber Birthdate

MonthDayYear
Date
Subscriber Phone Number

Area CodePhone Number
Subscribers' Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload a photo of the front of your insurance card:

Browse Files

Cancelof
Please upload a photo of the back of your insurance card:

Browse Files

Cancelof
Private Insurance Name of Company:
Private Insurance Company Phone #:

Area CodePhone Number
Group #
Insurance ID #
MonthDayYear
If the student is uninsured, you may apply for our sliding fee discount program.

Please call our office for an application 828-675-4116
Should be Empty:

Parent Permission Form

Photo/Social Media Informed Consent

Student Information

Mother/Guardian Information

Father/Guardian Information

Non-Parent Emergency Contact Information

Household Information

Biological Family Health History

Student's Health History

Insurance Verification Information

If the student is uninsured, you may apply for our sliding fee discount program.