The Lavaca School-Based Health Center (SBHC) is located on the Lavaca Middle School campus and serves all students and staff in our district, as well as community members. Our center offers medical, dental, and behavial health services. F me infmation about our SBHC and to register a student, please see the Wellness tab at www.lavacacshools.com. Lavaca SBHC Providers, Services, Hours, and How to Make an Appointment Medical Dental Behavial Health Provider of Services Lavaca Wellness Clinic: Dr. Robert Sanders, Jonathan Broniste, APN, and staff Services Offered Well-child check-ups Primary care f illness and injury Comprehensive annual exams Spts physicals Labaty tests Prescription medications Allergy testing Flu vaccinations (seasonal) Health promotion and prevention programs Hours of Operation How to Make an Appointment f a Student Referrals f services not provided by Lavaca Wellness Center Monday through Friday 8:30 a.m. 4:30 p.m. Last patient taken at 4:00 p.m. Student is assessed by school nurse Contact School Nurse Terri Crabtree 674-5618 Contact LES Nurse Susi Neissl 674-5613 Contact Lavaca Wellness Clinic directly at 674-9181 Friddle Dentistry: Dr. Cody Friddle and staff Regular Cleanings Extractions Fillings Crowns Zoom! Whitening Pcelain veneers Neuromuscular dentistry Dental implants Full mouth reconstruction TMJ therapy Functional thodontics, including braces Hygienist on campus every other Wednesday Dr. Friddle on campus once per month Student is assessed by school nurse Contact School Nurse Terri Crabtree 674-5618 Contact LES Nurse Susi Neissl 674-5613 Contact Friddle Dentistry directly at 674-9161 Western Arkansas Counseling and Guidance Center Individual counseling Intervention with a licensed therapist Family sessions Case management Group counseling Crisis intervention Assessments of students in crisis Regular school hours Students are seen by referral only, from school counsel, school nurse, medical provider. *Behavial health services are only offered to students enrolled in Lavaca Public Schools.
LAVACA SBHC FAQs (frequently asked questions): Does the general public have access to the school? No. The clinic is designed to provide safety and privacy f students. There is a secure access between the school and the clinic and it is only accessible to clinic staff responsible f escting students to the clinic f services where they will be taken directly to an exam room. The general public accesses the clinic from the nth side of the middle school. Do I have to pay f services? Most insurance plans are accepted including Medicaid and ARKids 1 st. A co-pay may be required; however, no child will be turned away because of inability to pay f services. What about prescriptions? No child will leave the Lavaca Wellness Center with a written prescription. All student prescriptions will be called sent electronically to the parent guardian s pharmacy of choice. What do I need to do f my child to receive services? Students needing services from the Lavaca Wellness Center must have parental consent fms on file in der to access services. All students needing services must visit the school nurse pri to receiving clinic services during school hours. Any child that is in need of services will be scheduled f a visit based on the acuity of the need. If it is determined by the school nurse that a student needs services of the Lavaca Wellness Center, the parent must be notified pri to the delivery of services. No student will ever be sent directly to the clinic during school hours without an assessment from the school nurse. Student and staff services will be scheduled as soon as possible based upon acuity. Do parents fav SBHCs? Yes. Parents appreciate SBHCs because: SBHC services help their child to stay healthy and in school. Parents miss less wk. Without a SBHC, when a child is sick, the parent misses wk to take the child out of school and be seen at the nearest health care facility. SBHC services are provided free to students whether not they have insurance & regardless of ability to pay. SBHCs make schools me prepared f emergencies. Parents feel me secure knowing that if a national other emergency occurred during school hours, trained medical practitioners are already on hand at the school. SBHCs can partner with schools in developing and implementing the schools crisis response plan, often making those plans stronger. SBHC staff can enhance the school s health education program. Hear about the benefits of Lavaca s SBHC by watching the video at this link: https://www.youtube.com/watch?v=wj4zwhxyyfy Do SBHCs interfere with parental authity? No. Statewide, parents retain the authity to sign consent fms regarding whether their child can be seen at the SBHC f standard services (such as treatment f colds, spts injuries, asthma). If medication is prescribed, the child s parent is notified. Shouldn't schools just focus on education? Schools cannot do their job of educating students if the students are not in school. Research shows that students who use SBHCs are less likely to be absent and me likely to be promoted graduate than their peers who do not. Furtherme, students without SBHCs are less likely to get medical care, so they often come to school sick, spread illnesses to their teachers and peers, and thus distract others from learning.
LAVACA SBHC FAQs continued Do SBHCs eliminate the need f school nurses and school counsels? No. SBHCs do not and will not replace school nurses counsels. Rather, they complement services already being provided by placing additional resources in the schools. In some cases, school nurses and counsels wk independently of the SBHC. Other schools choose to incpate them into their new SBHC. Either way, school nurses and counsels are vitally imptant to comprehensive health services f students. Do health centers take money away from schools? SBHCs get their funding from many different sources, including the state, private grants, and insurance billing. Schools provide in-kind suppt to their health centers, such as space, utilities, and custodial services. In addition, some school districts pitch in modest funding, recognizing that students are me successful when they are physically and mentally healthy. Our Vision: Students and staff of Lavaca Public Schools will have quality, integrated school health services that improve health status, optimize academic achievement, and enhance well-being. Our Mission: To collabate with other school health partners to promote, facilitate, and advocate f comprehensive, culturally competent health care in schools. Our Ce Values: We believe in universal access to affdable, high quality health care provided in schools and communities because good health is essential f student success, and health care, like public education, should be a right. We believe in advocating f the health of children and youth and f the provision of high quality, accessible, confidential, comprehensive, culturally competent health care in schools. We believe that, as a valuable component of the health care delivery system, SBHCs should be appropriately funded and reimbursed. We believe that preventive and primary health care should be available where children are, in school. We believe that children will not care what we know until they know that we care.
APPOINTMENT PROCEDURES FOR MEDICAL AND DENTAL A shuttle service is provided at no cost to elementary students who have doct dental appointments scheduled through our wellness center facilities when a parent guardian cannot be present f the appointment. If you are unable to attend your child s appointment, a district staff member will check your child out through the school s front office, transpt them in a district vehicle, and check them back in to their school building after the appointment. Middle and high school students are accompanied by the school nurse. The doct will contact you after the appointment to discuss the method of treatment. If you plan to attend the appointment with your child, please let the scheduling attendant know, whether through the clinic, dentist office, school nurse, so that district staff can plan accdingly. If you attend the appointment with your child you will need to check your child out and back in to their respective school. Elementary student appointments scheduled after 2:00 pm must be accompanied by a parent guardian as the appointment may last until after school is dismissed. Appointments f middle and high school students scheduled after 2:30 pm must be accompanied by a parent guardian.
Lavaca SBHC Lavaca Wellness Clinic Student Registration Fm Today s Date: Primary Care Physician (PCP): Patient Name: First Middle Last Home Address: Street City State Zip Preferred Phone: ( ) Alternate Phone: ( ) Birth date: Age: Male / Female SSN: Parent/Guardian Names: Mailing Address (If different from physical address): Street City State Zip Preferred Pharmacy: Phone ( ) Please list who we may notify in the event of an emergency: (Please list at least one contact outside of your household.) Contact: Contact: Relationship: Telephone: Relationship: Telephone: Complete this section if patient is a min if the patient is not financially responsible. Responsible Party: Relation to Patient: Birth date: Age: Male / Female SSN: Marital Status: Single Married Widowed Divced Spouse Name: Circle One Mailing Address (If different from patient): Street City State Zip Employer: Wk Phone: ( )
INSURANCE INFORMATION Student Name Student DOB / / Primary Medical Insurance: Group Number: Medical Insurance ID Number: Patient s relationship to insured: Self Child Other: Dental Insurance: Dental Insurance ID Number: Secondary Insurance infmation (if applicable): STUDENT HEALTH HISTORY Does the student have any drug allergies? YES / NO If yes, please let us know what medications you are allergic to and what type of reaction do you have to the medication? Student currently taking medications? YES / NO If yes, please list medication(s), dosage(s), and frequency (please attach a separate list with today s date, if me space is needed). Medication(s) Dosage Frequency
Has the student ever had surgery been hospitalized? YES / NO If yes, please list reason and date(s). Please list any conditions that the student has been treated f is currently being treated f. STUDENT S FAMILY HISTORY Alcoholism Asthma, Lung Disease Bleeding Disders Cancer Diabetes (specify type) Epilepsy, seizure disder Glaucoma Heart Disease High Blood Pressure Kidney Disease Mental Illness, depression, anxiety, ADHD, etc. Migraines Osteoposis Stroke Thyroid Disease Other (specify) Siblings Mother Father Mother s Parents Father s Parents Please list any other infmation that you feel is pertinent to your child s medical care:
PARENT CONSENT FORM Student Name: Date of Birth: / / Parents/Guardians: Please read the following statements, check the boxes, sign, and return. I understand the following types of services are offered through Lavaca Schools SBHC: Routine physical exams, including well-child checks & spts physicals Diagnosis & treatment of acute & chronic illness Treatment of min injuries Vision, hearing, dental, & blood pressure screenings Labaty tests Age appropriate reproductive health services (abstinence counseling, education, exams &referrals). * Preventive & restative dental treatments Dental radiographs Health education, counseling, and wellness promotion Nutrition education and weight management Prescription medications Behavial health Services Classroom presentations Student surveys & questionnaires Referrals f services not provided by Lavaca SBHC providers I understand my insurance may be billed f services provided by the SBHC. However, no student needing care will be turned away due to lack of health insurance ability to pay. I give my permission f the Lavaca SBHC providers to provide medical care, illness prevention and wellness promotion programs, and behavial health counseling services to the student named above. I give my permission f my child to receive health care from the following providers at the Lavaca SBHC: Robert Sanders, D.O., FACOI Jonathan Broniste, APN Friddle Dentistry Western AR Counseling & Guidance Center I understand the Lavaca SBHC providers are located on the Lavaca Middle School campus, and therefe it may be necessary f a student to be safely transpted from another campus in the Lavaca School District to and from the SBHC. I give my permission f my child to be transpted via mot vehicle/district s electric golf cart to/from a Lavaca School District campus by an employee of Lavaca Public Schools to/from the Lavaca SBHC. Parent / Guardian Signature Date Phone Number *Arkansas law does not require parental consent f examination and treatment of STDs, examination and diagnosis of pregnancy, family planning services, substance abuse counseling and treatment, and behavial health counseling and treatment. A parent/guardian will always be notified by phone befe the student receives any services, except in cases mentioned here.
ASSIGNMENT OF BENEFITS & AUTHORIZATION TO RELEASE RECORDS I certify that I, and/ my dependent(s), have insurance coverage with and assign directly to the appropriate provider at Lavaca School-Based Health Center all insurance benefits, if any, otherwise payable to me f services rendered. I authize the use of my signature on all insurance submissions. The above named providers may use my health care infmation and may disclose such infmation to the above named Insurance Company(ies) and their agents f the purpose f obtaining payment f services and determining insurance benefits the benefits payable f related services. HIPPA PATIENT ACKNOWLEDGMENT AND CONSENT I have received the Notice of Privacy Practices containing a complete description of the uses and disclosures of my health infmation and have had an opptunity to read and review all contents of said document. By signing this fm, you will consent to our use and disclosure of your protected health infmation to carry our treatment, payment activities, and health care operations. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices, which will contain the changes. These changes may apply to any of your protected health infmation that we may obtain. You have the right to revoke this consent at any time by giving us written notice of your revocation. Please understand that revocation of this consent will not affect the action we have will take in reliance to this consent befe we received your revocation, and that not signing this consent by revoking such consent in the future, we may reserve the right to refuse treatment. I authize the providers of the Lavaca School-Based Health Center (Lavaca Wellness Center, Friddle Dentistry, Western Arkansas Counseling & Guidance Center) to release any infmation pertinent to my case to any insurance company, adjuster, attney involved in my case. I authize the providers of the Lavaca School-Based Health Center (Lavaca Wellness Center, Friddle Dentistry, Western Arkansas Counseling & Guidance Center) to file my insurance f services provided. I have been notified of the Lavaca Wellness Center s Privacy Practices f Protected Health Infmation. Responsible Party Printed Name Responsible Party Signature Date Patient Name Date I wish to receive a printed copy of Privacy Practices f Protected Health Infmation f each of the Lavaca School-Based Health Center providers. I have been provided with a printed copy of Privacy Practices f Protected Health Infmation f each of the Lavaca School-Based Health Center providers.
Collabative Care Dental Hygiene Preventative Care Consent Fm Friddle Dentistry Cody Friddle, DDS (Lic. #3665) Jill Teague, RDH (Lic. #2240) 5008 South U Street Ft Smith, AR 72903 (479) 452.8800 Preventative services to be provided include: al screening, dental prophylaxis, sealants and fluide treatment. Please answer the following questions: 1. Has your child had dental care in the past 12 months? YES NO a. If yes, please list the name and address of the dentist dental home where the care was provided: 2. Does your child have an appointment scheduled at the dental home where care is nmally provided? YES NO a. If Yes, we recommend maintaining your relationship within a dental home and not receive services in a public setting. I understand that I can choose to have dental hygiene services provided at the dental home where care is nmally provided, rather than a public setting. I understand that all dental hygiene care provided by the dental home I have used in the past a Collabative Care dental hygienist will reduce future benefits that my child may receive from private insurance, Medicaid (ARKids) other third party providers of dental hygiene benefits f the remaining benefit period. I,, parent/guardian of, give consent f my child to receive dental preventative services in a public setting by Collabative Care Dental Hygienist, Jill Teague. Parent/Guardian Signature Date