School Based Health Center Enrollment

What We Offer

Our School-Based Health Centers offer a variety of health services conveniently on-site in your school and feature no out-of-pocket cost and no copays.

We also work directly with your primary care doctor and bill your insurance for services received. If you do not have a doctor or insurance, we will work with you to connecti with a doctor or obtain insurance.

Our team features family and pediatric nurse practitioners, licensed clinical social workers / therapists, and ambulatory technicians to provide services in your school building.

Services Provided

Treatment for injuries and illnesses
Prescriptions and over the counter medications for illnesses
On-site Lab services, including throat cultures, flu and covid-19 testing
Immunizations/Vaccines
Physicals for sports and work permit
Adolescent Health counseling
Mental Health Assessments, counseling and referrals
We provide after-hours coverage 24 hours a day 7 days a week for our patients by calling (585) 435-2332

Student Information

Which school does your child attend?*

East Lower/Upper

James Monroe High School

Student First Name*

Student Last Name*

Student Date of Birth*

Student's current grade*

Student Gender*

Female

Male

Non-binary

Unspecified or Other

Ethnicity*

Not Hispanic or Latino or Spanish origin

Hispanic or Latino or Spanish origin

Your ethnicity refers to your background heritage, culture, religion, ancestry or sometimes the country where you were born.

Student Address

Street 1*

Street 2

City*

State*

ZIP*

eg. 12345 or 12345-1234

Student Cell Phone

eg: 555-555-1212

Is it ok to text this number? Our SBHC Team may send appointment reminders via text from the SBHC cell phone.*

Yes

No

Not Applicable

Student's preferred email

Is it ok for the Health Center to email student? Our SBHC Team use e-mail to send general appointment reminders.*

Yes

No

Parent / Legal Guardian Information

Parent First Name*

Parent Last Name*

Relationship to Student*

Mother

Father

Grandparent

Other

Parent / Guardian's Address (if different than student address)

Street 1

Street 2

City

State

ZIP

eg. 12345 or 12345-1234

Best phone number to reach parent / guardian*

eg: 555-555-1212

Parent / guardian's preferred email address*

Is it ok for the Health Center to email parent / guardian?*

Yes

No

Emergency Contact Name*

Emergency Contact Relationship to Student*

Mother

Father

Grandparent

Other

Emergency Contact Phone*

eg: 555-555-1212

Student Brief Medical History

Primary Care Provider / Pediatrician

Primary Care Provider / Pediatrician Phone

eg: 555-555-1212

If your child has no health provider, may we contact you to assist with obtaining a pediatrician for your child?

Yes

No

Mental Health Provider / Agency

Mental Health Provider / Agency Phone

eg: 555-555-1212

List any allergies your child may have:

List any medications your child is taking:

List any health problems:

List any other health concerns:

Student Health Insurance Information

Does your child have health insurance?*

Yes

No

Parental / Legal Guardian Consent for School Based Health Services

I consent for my child , date of birth , to receive health care services provided by the University of Rochester Medical Staff as part of the School-Based Health Center program approved by the New York State Department of Health. I understand that confidentiality between the student and the health provider will be ensured in specific service areas in accordance with the law, and that students will be encouraged to involve their parents or guardians in counseling and medical care decisions. I further authorize the exchange of medical information with other medical providers who have examined the child named on this form and our insurance provider. School-Based Health Center services may include, but are not limited to:

Comprehensive physical examination (complete medical examination) including those for school, sports, working papers and new entrants.
Medically prescribed laboratory tests such as for anemia, sickle cell, and diabetes.
Medical care and treatment, including diagnosis of acute and chronic illness and disease, and dispensing and prescribing of medications.
Mental health services including evaluation, diagnosis, counseling, and referrals.
Reproductive health care services, including contraception, (birth control pills, Depo (the shot) etc,) testing for pregnancy, STD screening and treatment, HIV testing, PAP smears, and referrals for abnormal results, as age appropriate.
Nutrition and weight counseling.
Health education and counseling for the prevention of risk-taking behaviors such as: drug, alcohol and smoking abuse, as well as education on abstinence and prevention of pregnancy, sexually transmitted infections, and HIV, as age appropriate.
Referrals for service not provided at the school based health center.
Refractive vision screening for prescriptive eyewear.
Care is available 24 hours a day, seven days a week. Call (585) 435-2332 for After Hours care.

Our SBHC team will use our SBHCSON@URMC.ROCHESTER.EDU email and/or text messaging from our SBHC cell phone to send appointment reminders that only include day and time of your appointment. Because e-mail and text messages may not be secure, SBHC will NOT include personal health information, and we recommend that you do not provide personal health information in any reply for confidentiality reasons. For more information, visit our website https://son.rochester.edu/clinical/sbhc.html

I have read and understand the services listed above and my signature below documents consent for my child to receive services provided by the School-Based Health Center. NOTE: By law, parental consent is not required for the conduct of mandated screenings, the application of first aid treatment, pre-natal care, services related to sexual behavior and pregnancy prevention, and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students who are 18 years or older or for students who are parents or otherwise legally able to sign on their own behalf. Please review the SBHC information sheet for important documents. You may view the University of Rochester Notice of Privacy Practices at https://www.urmc.rochester.edu/medialibraries/urmcmedia/privacy/documents/NoticeofPrivacyPracticesHIPAA.pdf

Parental Consent Statement*

YES, I consent and I have read and understand the services listed.

NO, I do not consent

I agree that my electronic signature is the legal equivalent of my manual / handwritten signature on this document. Please type your name, to confirm that you have completed this form on July 2, 2024 to the best of your ability.

Parent Signature*

SBHC Important Information

Request / Obtain Medical Info

Patient Access Request Form

Patient's Bill of Rights:

Parent's Bill of Rights

I Reviewed the SBHC Important Information listed above. This information can also be found on our website: urson.us/sbhc*

YES

NO, I will review at a later time if needed

Parent / Legal Guardian Authorization for Release / Disclosure of Medical Information

Student Name :

Student Date of Birth :

My signature authorizes the exchange of medical information between the School-Based Health Center (SBHC) and the Rochester City School District's School Nurse Office in order for my child to receive health care services in the SBHC . I also consent to allow the SBHC access to my child's academic schedule to facilitate appointment scheduling and further consent to the exchange of information concerning appointment dates and times with my child's teachers. No medical information will be released to teachers by SBHC staff. I understand that only information required by state law and/or information to protect the health and safety of the student will be disclosed to the Nurse's Office and only information needed to provide continuity of care will be exchanged with other health care offices. I also consent to allow SBHC Mental Health providers to exchange the following information to the school's social and emotional team (Social Worker, Counselors, Psychologist): scheduled appointment dates and times, counseling treatment plan/goals and referrals provided to support my child's continuity of care for mental health/counseling services.

Information required by RCSD may include but is not limited to:

New Entrant exams
Immunizations
Vision and Hearing Screening Results
Tuberculin Test Results

Information to Protect Health and Safety may include but is not limited to:

Conditions which may require emergency medical treatment
Conditions which limit a student’s daily activity
Diagnosis of certain communicable diseases (not including HIV infection/STI and other confidential services protected by law).

I understand that:

I may cancel this authorization at any time by submitting a written request to the School-Based Health Center address 1801 E. Main Street Rochester, NY 14609 (attention Director for UR SBHC) or by e-mail sent to SBHCSON@URMC.ROCHESTER.EDU, except where a disclosure has already been made in reliance on my prior authorization.
If the person or facility receiving disclosed private health information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be re-disclosed.
If the authorized information is protected by Federal Confidentiality Rules related to substance abuse, it may not be disclosed without my written consent unless otherwise provided for in the regulations.
Release of HIV-related information requires additional authorization.
Access to School-Based Health Center services is not conditioned on this authorization.
Time Period During Which Release of Information is Authorized: Valid From: Date the form is signed To: Date that student is no longer enrolled in the School-Based Health Center or graduation date from Rochester City School District

Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law)*

YES

NO, I do not authorize information to be exchanged

I agree that my electronic signature is the legal equivalent of my manual / handwritten signature on this document. Please type your name, to confirm that you have completed this form on July 2, 2024 to the best of your ability.

Parent Signature*

Please confirm before submitting

To help us ensure the accuracy of your information, please confirm that the following items are correct before submitting.