Please return the entire 8-page Medical Form Packet as soon as possible. (No later than April 15, 2018)

Transcription

1 PHILLIPS EXETER ACADEMY EXETER SUMMER MEDICAL FORMS and INSURANCE INFORMATION Parents: The majority of our communication is via from We will use your preferred address provided to us on the Exeter Summer application page. When ing forms, please include your student s name and assigned Exeter Summer student ID number on the subject line of the . Please be sure to sign all highlighted signatures- forms will be returned if not complete. Please return the entire 8-page Medical Form Packet as soon as possible. (No later than April 15, 2018) healthformes@exeter.edu Fax: Mail: Lamont Health and Wellness Center 20 Main Street Exeter, NH Thank you! Page 1

2 E X ETER S U M M E R 2018 PHILLIPS EXETER ACADEMY EXETER, NEW HAMPSHIRE PATIENT S RIGHTS AND RESPONSIBILITIES: Phillips Exeter Academy (the "Academy") believes that the FOR OFFICE USE ONLY relationship among students, parents, and health care providers is strengthened by a mutual understanding of the basic rights and responsibilities of each of the parties. As such, all medical and psychological information shared between students and the Academy s health care providers is private and is treated confidentially within the limits of the law. The Academy strongly encourages students to develop relationships of trust with health care providers and to be candid about their health histories and risk behaviors. We also encourage students to communicate with parents on such matters. In this effort to promote candor and trust, the Academy asks that parents respect the privacy of students who may not wish to share certain information. While it is the obligation of every employee and agent of the Academy to safeguard and keep patient medical information confidential, the Academy must also balance matters of privacy and confidentiality with safeguarding the interests and well-being of our students and our community. Thus, parents and students consent to allow the Medical Director of the Lamont Health and Wellness Center of the Academy (the "Medical Director"), counselors or their designee to disclose to those authorized employees and agents of the Academy, who have a need to know, the minimum amount of medical and/or psychological information necessary to serve the best interests of the student and/or the community. Students and parents who have questions with regard to confidentiality and its limits should direct those questions to the Medical Director or his/her designee at the Lamont Health and Wellness Center. In the event of a disclosure required by law, every effort will be made to notify the student and /or parents in advance. I also acknowledge receipt and review of the Patient's Rights and Responsibilities policy. SIGNATURE OF PARENT/GUARDIAN SIGNATURE OF STUDENT DATE PERMISSION FOR MEDICAL CARE AND AUTHORIZATION FOR RELEASE OF INFORMATION: I hereby give consent for the Medical Director or other health care providers including, but not limited to Exeter Hospital, Inc. to carry out accepted procedures for diagnosis, immunization, medical and minor surgical treatment, or counseling for my son/ daughter/ ward, (student s name: print student name, last, first, middle initial) (In rare instances a medical, surgical, or psychiatric emergency arises in which written consent by the parent or guardian is legally required, but the proper person cannot be located. In such circumstances, in order to avoid delay which might jeopardize the life or recovery of a student, we also request the following permission from the parents or guardian, with the understanding that every effort will be made to contact them in an emergency.) I hereby grant permission to the Medical Director or his/her designee, and other health care providers, including, but not limited to Exeter Hospital, Inc. to give emergency care, necessary anesthesia, and perform emergency surgery on my son/ daughter/ ward. I hereby grant permission to the medical director or his or her designee to have access to my son/daughter/ward s medical record in the event of admission to Exeter Hospital. I hereby grant permission to Exeter Hospital providers (MDs, RNs, Counseling Services) to discuss my son/daughter/ward s medical/psychological condition with Phillips Exeter Academy Health Services providers in the event of hospital admission. I hereby authorize the Medical Director or his/her designee and other health care professionals who have provided health-related services to my son/daughter/ward to release medical information (including information related to drug/alcohol treatment), as required to carry out treatment, health care operations (e.g. quality assessment and licensing reviews), and payment, unless more specific authorization is required by law. I also authorize other health care providers who have provided medical treatment or related services to my son/daughter/ward, including, but not limited to Exeter Hospital, Inc., to release medical information (including information related to drug/alcohol treatment) to the Lamont Health and Wellness Center or other health care professionals as required to carry out treatment and health care operations, unless more specific authorization is required by law. I authorize the release of medical information to my insurance company (including the Academy student health plan) as may be necessary to determine benefits entitlement and to process payment claims for health care services rendered. When parents are separated or divorced, absent a court order to the contrary, the Academy presumes that a non-custodial parent has access to health information and input to the same extent as a custodial parent. My signature below indicates my consent to the above matters. This consent will remain in effect throughout the 2018 Exeter Summer unless it is revoked by me or my son/daughter/ ward's other parent or guardian. SIGNATURE OF PARENT/GUARDIAN SIGNATURE OF STUDENT DATE Telephoning You: List in order of preference for being telephoned and circle home H, work W or cell C: Name: Tel: Name: Tel: Name: Tel: H or W or C H or W or C H or W or C Student Cell Phone: Parent Address: Parent/Guardian Names (please print): Page 2

3 Student s Name: D.O.B.: / / TO THE STUDENT/PARENT: This information is strictly for the use of the Health Services in providing care. It will be treated confidentially. Please inform Health Services if there is any change of condition between completion of this form and the start of Exeter Summer. PERSONAL HISTORY: Please complete in full. COMMENT ON ALL POSITIVE ANSWERS IN THE SPACE PROVIDED OR ATTACH A SEPARATE SHEET. Do you have or have you ever had? ADHD/Learning Disability Alcohol or Other Drug Use Anemia/Blood Disorder Asthma/Wheezing Back Problems Birth Control Method Cancer/Tumor Chest Pain/Shortness of Breath Counseling/Psychotherapy Dental Problems Depression Diabetes Ear, Nose, Throat Problems Eye Problems Fainting/Loss of consciousness Fractures/Sprains/Dislocations Headaches Head Injury/Concussion Heart Disease High Blood Pressure Intestinal/Digestive Problems Jaundice/Hepatitis Kidney disease/bladder Infections Measles Mononucleosis Mumps Pneumonia Recent Weight Change/Eating Concerns Rheumatic Fever Seizures Sexual Activity Sexually Transmitted Disease Significant Anxiety/Depression Sinusitis Skin Problems Special Diet TB Thyroid/Hormone Problems Tobacco Use Women Menstruation: Age of Onset Menstrual Problems Other Illness Yes No If you answered yes to the above, please explain: PERSONAL HISTORY Please complete in full. Medication & /Dosage (regular or as needed) Allergies to Medication Reaction Allergies to Food Reaction Other Allergies What treatment is needed? Allergy Injections Epipen? (please attach detailed information from physician) Have any of your biological relatives had Yes No Relationship Arthritis Asthma/Hay Fever Diabetes Heart Disease High Blood Pressure Intestinal Disease Migraine Headaches Mental Health Diagnosis Seizures Thyroid Disease Tuberculosis Hospitalizations (date & diagnosis) Surgery (date & diagnosis) Significant Illness (date & diagnosis) FAMILY HISTORY (BIOLOGICAL) Relationship Age State of Health Father Mother Brothers Sisters Medical Problem(s) Are your parents separated? Yes Divorced? Yes When? No No Who has custody? Page 3

4 EXETER SUMMER PHYSICAL EXAMINATION TO BE COMPLETED BY PHYSICIAN (within one year prior to entry) TO THE PHYSICIAN: THIS FORM MUST BE FILLED OUT IN ITS ENTIRETY. PLEASE REVIEW THE STUDENT''S HISTORY and complete this page. Please include with this form a separate letter detailing the medical history and management plan for any serious or chronic illness. Student Name Last First Middle Sex: M F D.O.B.: / / Height Weight Blood Pressure Pulse Recommended Urinalysis Hematocrit/Hemoglobin Hearing Right Vision Uncorrected -Right -Left Corrected -Right -Left Left Are the following systems normal? Yes No Findings Skin Head, Eyes Ears, Nose, Throat Thyroid, Lymph Nodes Chest/Lungs Breasts Heart Abdomen Genitourinary Back/Extremities Neurological Psychological Medications: Please list any medication allergies: Is there loss or serious impaired function of any paired organ? Yes No *Have there been any significant medical problems not noted above? Is there any reason to restrict activities? *Do you recommend any further evaluation or therapy? (Non-parent physician) Physician/ARNP/PA Signature: Print Last Name: Address: Telephone#: ( ) Date: *Physician: Please send a detailed summary of any chronic illness or medical problem including treatment and recommendations. Return to: Page 4 Phillips Exeter Academy Lamont Health and Wellness Center 20 Main Street Exeter, NH Tel: (603) OVER

5 Student s Name: D.O.B.: / / THIS FORM MUST BE COMPLETED EVEN IF YOU ARE ATTACHING A COPY OF AN IMMUNIZATION RECORD. The following immunizations are REQUIRED by New Hampshire State Law, and must be administered in order to attend Exeter Summer: Please indicate as month/day/year. IMMUNIZATIONS AND TUBERCULIN TEST: Diphtheria/Pertussis/Tetanus: Completed primary series of DTP/DTaP/Td/Tdap. Date of dose 1 / / Tdap Booster required (must be within last 10 years) Date of dose 2 / / Date: / / Date of dose 3 / / Date of dose 4 / / Date of dose 5 / / Polio: Completed primary series as above. Date of dose 1 / / OPV/IPV circle one Date of dose 2 / / OPV/IPV circle one Date of dose 3 / / OPV/IPV circle one Date of dose 4 / / OPV/IPV circle one Tuberculin Test: (PLEASE REVIEW AND COMPLETE TUBERCULOSIS SUPPLEMENT FORM) Hepatitis B (required) Date of dose 1 / / Date of does 2 / / Date of does 3 / / Hepatitis A (recommended) Date of dose 1 / / Date of dose 2 / / Measles/Mumps/Rubella (MMR): (required) Date of dose 1 / / Date of dose 2 / / Varicella (required if no history of disease) Date of dose 1 / / Date of dose 2 / / Hx of disease Date Other Immunizations: OVER Page 5

6 2018 MEDICAL HISTORY FORM TUBERCULOSIS SUPPLEMENT The following form must be completed in full and returned with the Medical Forms. If you check one of the boxes in section 1-4, you are required to have a tuberculosis (PPD) skin test in the past 12 months. Check the box in Section 5 if sections 1-4 do not apply to you. This form MUST be signed and dated by Parent/Guardian. Have you had a BCG vaccine? Yes No The Centers for Disease Control and Prevention and the United States Public Health Service recommend that the tuberculosis skin testing be performed on anyone who may be at increased risk of tuberculosis as a result of a medical condition or previous residence in a country with an increased prevalence of tuberculosis. Section 1: Check this box if you have any of the following possible symptoms of tuberculosis: Unexplained weight loss Unexplained persistent cough for more than three weeks Unexplained elevation of temperature for more than one week Unexplained cough productive of bloody sputum Unexplained night sweats Section 2: Check this box if you have any of the following risk factors for tuberculosis infection: Close contact with a known case of active tuberculosis Use of illegal injected drugs HIV infection Health care worker/volunteer Volunteer in a group living setting such as a nursing home, homeless shelter, jail, etc. Section 3: Check this box if you have any of the following risk factors for tuberculosis disease: Diabetes mellitus Gastrectomy or jejuno-ileal bypass Lymphoma, leukemia, or cancer of the head, neck or lung Long-term steroid (immunosuppressive) therapy Chronic kidney failure Greater than ten percent below ideal body weight Silicosis Section 4: Check this box if, in the last five years, you have lived in or traveled for 30 days or more to any of the following areas with a high prevalence of tuberculosis as defined by the World Health Organization: Africa: All countries Asia/Southeast Asia/Pacific Islands: All countries North, Central and South America: Argentina, Bahamas, Belize, Bolivia, Brazil, Costa Rica, Columbia, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Venezuela Europe: Belarus, Bosnia-Herzegovina, Bulgaria, Croatia, Estonia, Hungary, Latvia, Lithuania, Macedonia, Moldovia, Poland, Portugal, Romania, Russian Federations, Serbia, Slovak Republic Slovenia, Ukraine Middle East: Bahrain, Iran, Iraq, Israel, Jordon, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Turkey, Yemen Section 5: No, none of the items listed in Sections 1-4 apply to me. IF YOU ANSWERED YES TO 1-4, YOU MAY BE AT INCREASED RISK FOR TB. PLEASE GIVE THIS FORM TO YOUR MEDICAL PROVIDER. TB Skin Test Date Result mm induration If positive skin test (over 10mm induration) Date of Quantiferon/IGRA blood test Date Result If positive Quantiferon/IGRA blood test Date of Chest x-ray Result If taking medication for Positive TB test please list medication name Date Started Duration of treatment Name of Student (please print) Signature of MD/DO/ARNP/PA Signature of Parent/Guardian (relationship to student) Date Page 6

7 Phillips Exeter Academy Exeter Summer 2018 PRIVATE HEALTH INSURANCE FORM Student s name: D.O.B.: / / Please choose what applies: My child does NOT have private insurance coverage ( ) My child is enrolled in the 2018 Academy Student Injury and Sickness Plan ( ) Yes ( ) No My child is covered by a private insurance plan [ provide information on following pages] ( ) SECTION I: PRIVATE INSURANCE COVERAGE INFORMATION Insurance Company Name: Identification No.: Group No.: Address: City: State: Zip: Phone: Fax: Policyholder Last Name: First Name & Initial: Policy holder D.O.B. Relationship to Student: Prescription Coverage: YES NO Insurance referral authorization required? YES NO Please notify us at should there be any changes in your insurance plan or coverage. SECTION II: PRIVATE INSURANCE CARD Please make a clear copy of the front and back of your private insurance card and attach them to this form. Insurance Card: (front) Please tape or glue the copy of the card DO NOT STAPLE Insurance Card: (back) Please tape or glue the copy of the card DO NOT STAPLE Phillips Exeter Academy Lamont Health and Wellness Center 20 Main Street, Exeter, NH Telephone: Fax: healthformes@exeter.edu

8 Phillips Exeter Academy Exeter Summer 2018 PRESCRIPTION BENEFIT FORM Student s name: D.O.B.: / / SECTION III: PRESCRIPTION BENEFIT CARD Please make a clear copy of the front and back of your prescription card and attach them to this form. If your health insurance and prescription card are the same, please attach another copy to this page. Prescription Card (front) Prescription Card (back) You will be required to contact the pharmacy directly with payment information for any prescription cost or copay. Pharmacy information: Rite Aid Pharmacy, 28 Portsmouth Ave, Stratham, NH My child is enrolled in the 2018 Academy Student Injury and Sickness Insurance Plan ( ) Yes ( ) No Phillips Exeter Academy Lamont Health and Wellness Center 20 Main Street, Exeter, NH Telephone: Fax: healthformes@exeter.edu