New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.

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1 The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students. We also offer age appropriate vaccinations. If you would like your child to have their vaccines updated, please contact the health center for additional information. If you would like your child to receive medical or mental health services at the health center, please complete and sign the enclosed enrollment form and return it to the center or school office. If you need additional space to answer questions or if there is anything else you need us to know, please attach additional pages. In order for your child to receive dental services at the Richwood SBHC, you will need to complete the attached, separate dental program enrollment form. Dental services are intended for students who do not have a regular dentist. New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay. The Richwood School-Based Health Center will be open Monday through Friday from 7:30 to 3:30. The health center is located across from the cafeteria in Richwood Middle School. Like us on Facebook to get updates and information about School-Based Health and other New River Health services. Attached is a list of common questions and answers regarding the Richwood School-Based Health Center. If you have questions or concerns, please feel free to call us at RICHWOOD SCHOOL-BASED HEALTH CENTER PROVIDERS Angie Barker, PA-C Medical Provider James Powell, LICSW Mental Health Counselor Terra Basham, RDH Dental Hygienist The Richwood School-Based Health Center is a Practice Site of New River Health Association. 1

2 Questions and Answers about the School-Based Health Center What is a School-Based Health Center (SBHC)? SBHCs are clinics located in a school or on a school campus and provide the students with medical, mental health, dental, and health education services. School-based health centers work to improve the health of students, increase access to health care, and decrease time lost from school by providing health care in the school. Services provided include: immediate care for illness or injury, physical exams and sports physicals, medically prescribed laboratory tests, health education for students and parents, immunizations, management for chronic illnesses, individual, family and group mental health counseling, on site dental services and vision services through referral. New River Health provides after-hours phone call coverage for all SBHC patients seven days per week. Please call after hours with any health related concerns. Billing Information In order to obtain our SBHC services, New River Health (NRH) will bill private insurance, Medicaid and the Children s Health Insurance Program (CHIP) for eligible students. No student will be denied access to health care services due to inability to pay. If you have any questions about billing, please contact the SBHC or the NRH billing department at Will signing up at the School-Based Health Center mean that we can t use our family doctor? If we have a family doctor, do we need the School-Based Health Center? If you have a family doctor, you can still use the SBHC. You may find it convenient for your child to get medical care if they get sick or injured at school. You may want your child to be able to access counseling and health education services offered through the SBHC. This service is not meant to replace your family doctor, it is meant to compliment the services your family doctor provides and to help students who do not have a family doctor. Can I select which services my child can use at the School-Based Health Center? Yes. The SBHC services are listed on the enrollment form. Mark a line through the services you do not want your child to receive. There is also space for you to write in any additional comments. The SBHC staff will check your consent form before they see your child and will know which restrictions you have identified. Parents are always encouraged to contact the SBHC staff with questions or concerns and are welcome to accompany children to their appointment. Will my child s medical information be kept confidential? Your child s medical information will be treated with strict confidentiality. If you would like the center to discuss your child s condition with the school, please contact us. Otherwise, it is your responsibility to notify the school of any medications, allergies, or medical problems that may affect your child during school. By signing the enrollment form you are giving the school-based health center, your child s primary care physician (if applicable) and the Nicholas County school nurses permission to communicate and share medical information regarding your child s medical condition on a needed basis and with the understanding that this information will continue to be treated in a confidential manner. Also, by signing the enrollment form, you are giving the Nicholas County Board of Education permission to release your child s immunization records to the SBHC. Who do I call for more information? 2

3 Please call with additional questions, suggestions or concerns, or to obtain information on applying for Medicaid or CHIP. In order for your child to receive services at the health center, please read this form carefully, complete the questions and sign. Name of Child: Male Female (Please list child s name as it appears on birth certificate) Race (Circle): Caucasian Black Asian Other: Child s Date of Birth Grade Child s Social Security Number Ethnicity (Circle): Non-Hispanic/Non-Latino Hispanic/Latino Mailing Address City State Zip Code Child s Place of Birth: City Mother s Maiden Name: State Parent/Legal Guardian Information Parent/Guardian Name Relationship to Child Date of Birth Parent/Guardian Social Security Number Home Phone Number Cell Phone Number Work Phone Number Parent/Guardian Address Please list any individual other than yourself who we can contact in case we can t reach you in an emergency: Name: Relationship to Child: Home Phone: Cell Phone: Name: Relationship to Child: Home Phone: Cell Phone: Health History Information 1) Is your child allergic to any medications? Yes No If yes what? Does your child have any other allergies? (Such as foods, pollens, insect bites, etc.) Yes N0 if yes what? 2) List current medications your child is taking now: Medication/Dose Reason How long taking medication 3) Has your child ever had any serious or sports related injuries, surgeries or been hospitalized overnight? Yes No If yes, explain: 4) Has there been any change in your child s health during the past year? Yes No If yes, describe the illness or injury: 5) Has your child ever received mental health counseling services? Yes No If yes, when? 6) Immunizations: Please attach a copy of your child s immunization record. 7) Please check if your child has ever had any of the following health conditions: Allergies Anemia or blood disorders Asthma Bladder or kidney infections Cancer Chicken Pox Diabetes Endocrine/Gland Disease Hepatitis Headaches/Migraines Mononucleosis Mental illness or depression Pneumonia Rheumatic Fever/Heart Disease Scoliosis Seizures Severe Acne Sports Injuries or fractures Thyroid Disease Tuberculosis Ulcer or Digestive problems Pregnancy Other 8) When was your child s last dental exam? Name of dentist: 3

4 9) Are there smokers in your house? Yes No 10) If we need to call in a prescription for your child, which pharmacy would you like us to call? 11) Would you like for the SBHC to do a physical exam on your child during the school year? Yes 12) Please check if you or any of your child s blood relatives (parents, grandparents, aunts, uncles, brothers or sisters) living or deceased had/have any of the following problems. Please state the relative s relationship to your child. Condition Yes Relationship Condition Yes Relationship Alcoholism/Drugs High Cholesterol Allergies/Asthma High Blood Pressure Arthritis Kidney Disease Birth Defects Lung Disease Blood Disorders Tuberculosis Sickle Cell Anemia Mental Health/Depression Cancer (type ) Mental Retardation Diabetes Obesity Endocrine/Gland Disease Seizures/Epilepsy Heart Attack Stroke before age 55 13) In the past year, have there been any changes in your family such as: Marriage Serious illness Change in school Moved to a new home Separation Loss of job Birth Divorce Death Other: 14) Does your child have a family doctor or pediatrician? Yes No If yes, please list their name: and date of your child s last complete physical exam?. 15) Does your child have any special needs (physical handicap, learning disabilities, special dietary needs, etc.)? Yes No If yes please explain: 16) Head of Household: Total Number of People in Household: Gross Monthly Income in Household: $ List each household member and their income below Name Date of Birth Relationship to Child Income (circle frequency) Insurance Information Is your child covered by an insurance plan? Yes No If yes, please fill in the appropriate section below. In order for us to sustain the SBHC at your child s school we depend on the ability to bill insurances. Please complete the insurance information below. If you do not have insurance please contact your child s SBHC for information on insurance plans your family or children might qualify for. Medicaid Information Please circle your child s Medicaid carrier below: Molina Unicare Coventry The Health Plan WV Family Health Plan Medicaid ID#: Carrier ID#: PCP/HMO Provider: Provider Phone: Children s Health Insurance Program (CHIP) Name listed on card: ID# on card: Social Security Number of Card Holder: - - Birth date of card holder: 4

5 From (month/year): To (month/year): Other Insurance Information Insured Parent/Legal Guardian: Birth Date of Card Holder: SSN of Card Holder: Card Holder Address (if different from child): Insurance Company and Complete Address: Insurance Company Phone Number: Place of Employment: Group Number: ID Number: Services Offered by the School-Based Health Center Draw a line through services you do not wish for your child to have from the list below. Physical Exams Sports physicals Treatment of illness & injury Mental Health Counseling Health Education *Dental exams/cleanings/x-rays Lab tests Management of Chronic illness Immunizations Vision by referral * Must complete attached dental enrollment form to receive dental services Additional Comments: The above information is accurate and complete to the best of my knowledge. I have completely disclosed all known allergies, chronic illnesses, prior medications or drugs that have resulted in adverse reactions, and current medications with respect to my child. By signing below, I authorize my child to be seen at the Richwood School-Based Health Center. I agree to all services except the ones I have listed above. I, the parent/guardian of said student, give consent for my child to receive services at Richwood School-Based Health Center. I understand that this consent form will be good until my child leaves this school or until I provide the health center staff with written directions otherwise. All healthcare information is confidential. By signing the consent form below you are giving the SBHC, school nurse and your child s regular doctor (if applicable) permission to communicate and share medical information regarding your child s medical condition on an as needed basis with the understanding that this information will continue to be treated in a confidential manner. The health center may release information regarding treatment to third party payors for billing purposes. Child s name Date of Birth Parent/Guardian Signature Date Relationship to Child By signing below I am acknowledging that I have received a copy of the NRHA Notice of Privacy Practices (copy attached). 5

6 Signature of Parent or Legal Guardian Date Richwood School-Based Health Center Dental Program Enrollment Form If you do not want your child to receive dental services or if they have a regular dentist, please do not complete this form. New River Health will offer preventive dental services at Richwood School-Based Health Center including: dental X-rays, cleanings, fluoride treatments, sealants, and exams by a licensed dentist. If your child needs further treatment, such as fillings or orthodontics we will send home information on how to obtain these services. If you would like your child to take advantage of these services, please read this form carefully, complete the questions, sign and return. Our goal is to make dental services more accessible for children who are not regularly able to go to the dentist. New River Health will bill private insurance, Medicaid, and the Children s Health Insurance Program for eligible students, no child will be denied services due to inability to pay. Please include a copy of the dental insurance card. If your child does not have dental insurance please contact the health center for additional information. Cleanings are only recommended twice a year, therefore most insurance companies will only cover two cleanings yearly and x-rays one time yearly. *Only complete this form if your child does not have a regular dentist and you wish for your child to receive dental services.* Child s Name: Date of Birth: o Yes - I would like for my child to receive dental services (exams, sealants, fluoride, cleanings, x-rays) at the School-Based Health Center and understand that my child may be referred to a local dentist for further treatment. Parent/Guardian Name: Parent/Guardian Signature: Date: Does your child have a dentist: Yes No Name of dentist Date of last visit? List any food or drug allergies your child has: List any medications your child is taking: Does your child have any of the following conditions? Please circle all that apply. Requires Pre-Med Antibiotics Blood Disorders Autism ADHD Heart Murmur Congenital Heart Disease Artificial Heart Valves Seizures Other conditions not listed: Please list any surgeries your child had in the past 5 years, and dates of each surgery. Child s Insurance Information Please complete all that apply and provide insurance number or copy of card o Name of Dental Insurance Company: Policy # Address: Group # Employer: Phone # Name of Cardholder: Birth Date: Soc. Sec. # o Medicaid - Medicaid Number: o Chip (WV Children s Health Insurance Program) ID Number: Name on Card: 6

7 o No Dental Insurance 7