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1 We ve teamed up to make it easier for students to access healthcare in their school! Together, we are your School-Based Health Center! Waianae High School (WHS) is proud to partner with Waianae Coast Comprehensive Health Center (WCCHC) to provide a School-Based Health Center (SBHC) at WHS. WCCHC gives students an opportunity to be seen by a licensed health care provider without having to miss school. The following 4-page registration form includes a parent/legal guardian-representative consent. STAFF CONTACT INFORMATION AND HOURS Our staff includes licensed health care providers to assist students and we are available to communicate with the parent/legal guardian-representative of each child. We want to know your concerns and be able to keep you updated on your child s health. Feel free to contact us during office hours. SUMMER 2017 Monday Friday June 19 July 7 (8:00 am 12 noon) July 24, 25, 31 & August 1 (8:00 am 1:00 pm) HALE OLA KINO MAIKA I CONTACT INFORMATION Farrington Highway 2 nd Floor, Building B Waianae, HI PH. (808) Fax (808) HOURS OF OPERATION FALL SEMESTER Monday, Wednesday, Friday 7:45 AM 2:45 PM Tuesday and Thursday 7:45 AM 1:45 PM August 7, 2017 May 31, 2018 CLOSED: July 8 23, 26, 27, 28 August 2, 3, 4 NOTE: Clinic hours subject to school calendar. Making it easy for students to receive health care right in their own school! We accept most health insurance plans Convenient one-stop medical care at your school Walk-ins are welcome Keeps students in school Eliminates parents time away from work Flexible appointments are available Full-time board-licensed medical staff
2 Waianae Coast Comprehensive Health Center & Waianae High School SCHOOL-BASED HEALTH CENTER REGISTRATION and CONSENT FORM STUDENT Last Name First Name Middle Initial Male Female Date of Birth (mm/dd/yyyy) Gender Address (Street) City, State Zip Code Mobile Phone Home Phone RACE (please check ONE): Native Hawaiian (Hawaiian/Part Hawaiian) American Indian/Alaska Native Asian (Japanese, Chinese, Vietnamese, Laotian, Filipino, etc.) Black/African American Hispanic/Latino (Puerto Rican, Mexican, Guatemalan, etc.) Other Pacific Islander (Tongan, Samoan, Micronesian, etc.) White/Caucasian (Including Portuguese) STUDENT HEALTH HISTORY CITIZENSHIP (please check ONE): U.S. Citizen by Birth Naturalized Citizen Immigrant Permanent/Alien ETHNICITY (please check ONE): Hispanic or Latino Not Hispanic or Latino Allergies to food or medications Disabilities CURRENT MEDICATIONS: Medication/Supplement Dosage Medication/Supplement Dosage CHECK ANY OF THE FOLLOWING THAT APPLY TO THE STUDENT S HEALTH HISTORY: ADHD Anemia Asthma Bleeding Disorder Cancer Chronic Sinusitis Depression Diabetes Epilepsy Eating Disorders Esophageal Reflux Heart Disease Heart Murmur Hearing/Vision Growth Problems Hepatitis High Cholesterol HIV + /AIDS Kidney Disease Latex Allergy Liver Disease Pregnancy (Teens) Seasonal Allergy Seizure Disorder Sickle Cell Disease Sexually Transmitted Diseases (STDs) Stomach Problems Weight Problems Other Doctor/Pediatrician Phone Number Pharmacy of Choice Phone Number ALTERNATE CONTACT INFORMATION (if parent/legal guardian-representative is unavailable): Print Name Work/Home Phone Mobile Phone
3 PARENT OR LEGAL GUARDIAN-REPRESENTATIVE Yes No Father s Name: Last Name First Name Middle Initial Lives with you Father s Contact Information: Yes No Mother s Name: Last Name First Name Middle Initial Lives with you Mother s Contact Information: STUDENT MEDICAL INSURANCE (Please complete the information below) Name of Health Insurance Plan Policy Number Group Number Guarantor: Last Name First Name Middle Initial Address City State Zip Code Guarantor Date of Birth Guarantor s Contact Information: Guarantor Employer FINANCIAL INFORMATION (Complete this section only if you do not have medical insurance) Number of People in Household: Gross Monthly Family Income: $ Are you homeless? Yes No If yes, please check one: Shelter Transitional Doubling Up Street
4 PARENT/LEGAL GUARDIAN-REPRESENTATIVE CONSENT FOR STUDENT TO RECEIVE SERVICES AT THE SCHOOL-BASED HEALTH CENTER I, the parent/legal guardian-representative of said student, give consent for the student to receive all services at Waianae High School s School- Based Health Center including medical (e.g. vaccinations, physical exams, evaluation of injuries, and referrals) and behavioral health services (e.g. screenings, diagnoses, therapy, and referrals). I understand that youth 14 and above may consent to their own outpatient behavioral health services. SBHC staff will encourage every student to involve his/her parents/legal guardian-representatives in health care decisions. I understand that I may receive more information about minor consent services. I understand that the student s healthcare information is confidential, but that in certain instances, law allows or requires use and disclosure to others including if (1) you or the student authorizes the release of information, (2) a court so orders, (3) the student presents a danger to the student or others, or (4) child or elder abuse/neglect is suspected. I understand that SBHC is operated by WCCHC in cooperation with Waianae High School. It is not part of, or directly operated by Waianae High school. I understand that SBHC is operated by WCCHC and certain records about the student and the student s treatment shall be kept in written and computerized form and may be reviewed by other providers at WCCHC as needed. I understand that the student may be seen by a trainee/student who is identified as such and that all services provided will be supervised by a licensed provider. I have the right to refuse services by a trainee/student. I understand that no student will be denied access to health services due to inability to pay. As in any health center, there may be a charge depending on the service provided. When available, insurance will be billed. I understand that SBHC may release information regarding treatment to third party payers for billings purposes. I agree to pay my portion of the student s costs, if any, associated with services received. I am the parent/legal guardian-representative of the student. I understand that if guardianship or representation changes, a new consent must be signed by the legal guardian-representative. I also understand that by providing an alternative contact, if I cannot be reached, medical information regarding the student may be shared between the medical provider and the alternative contact. I understand that this consent form is valid for the student s entire enrollment at Waianae High School or until I provide SBHC staff with written directions otherwise. CONSENT TO ADMINISTER MEDICATION I agree to my child receiving any medication(s) required for his/her care at the School-Based Health Center. I understand that medications, or a generic equivalent, will only be administered by a Medical Assistant or Registered Nurse per a Doctor s or Nurse Practitioner s order. My child may receive all medications offered at the School-Based Health Center, except for the following: Preferred Pharmacy (Name & Location): CONSENT TO RELEASE INFORMATION By signing below, I give authorization for Waianae Coast Comprehensive Health Center to release to Waianae High School copies and/or updates of my child s immunization and/or Sports Physical Exam s/he received at the SBHC.
5 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires all physicians and health are facilities to provide patients with a notice describing how an individual s medical information may be used and disclosed, and how a patient may obtain access to their personal health information. A copy of this policy is located at the School-Based Health Center or can be obtained from our sponsoring center s website, You must sign below, indicating that you have received notification on how to obtain a copy of our HIPAA policies prior to the student receiving services. Return completed registration form (4 pages) to WHS School-Based Health Center 2nd Floor, Teacher s Lounge, Building B
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