Important Notice & Consent
PARENTAL CONSENT FOR SCHOOL-BASED ORAL HEALTH CLINIC SERVICES
I have read and understand the services listed on the next page (School-Based Oral Health Clinic Services) and my signature provides consent for my child to receive services provided by the Smile New York Outreach LLC School-Based Oral Health Clinic for as long as my child is enrolled at school. I may withdraw my consent at any time by written notice to Smile New York Outreach LLC. I have read the IMPORTANT HEALTH QUESTION above and will report any significant changes in my child’s health to 855-481-8638. We may send you text messages about the school dental program. Message and/or data fees may be charged by your wireless service provider; to discontinue, reply “STOP” to any message received from us. You also agree to receive pre-recorded and/or auto-dialed telephone calls relating to the school dental program at the land-line and/or mobile telephone numbers provided on this consent form. NOTE: By law, parental consent is not required for students who are 18 years or older or for students who are parents or legally emancipated. My signature indicates I have received a copy of the Notice of Privacy Practices.
SCHOOL-BASED ORAL HEALTH CLINIC SERVICES
I consent for my child to receive oral health care services provided by the State-licensed health professionals of Smile New York Outreach LLC as part of the school oral health program approved by the New York State Department of Health for as long as my child is enrolled at school. I may withdraw my consent at any time by written notice to Smile New York Outreach LLC. I understand that confidentiality between the student and the oral health clinic provider will be ensured in specific service areas in accordance with the law, and that pupils will be encouraged to involve their parents or guardians in counseling and oral care decisions. School-Based Oral Health Clinic Services may include, but are not limited to, preventative oral health services, restorative services, and emergency procedures. Preventative oral health services include, but are not limited to, comprehensive dental exams, dental hygiene treatments, x-rays, sealants and fluoride treatments. This may also include the application of Silver Diamine Fluoride on back teeth to halt the progression of cavities. (The use of Silver Diamine Fluoride may discolor any cavities to a brown or black color.) For services other than comprehensive dental exams and preventative oral health services, Smile New York Outreach LLC shall notify the parent/guardian of the services and treatments to be provided, including but not limited to fillings, extractions, pulpotomies and the use of anesthetics or other medications. If the parent/guardian does not consent, these services shall not be performed. I authorize & direct Smile New York Outreach LLC to bill & collect payment from Medicaid or any other insurance payer.
NEW YORK CITY DEPARTMENT OF EDUCATION’S
FACT SHEET FOR PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION
HIPPA COMPLIANT PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION
My signature on the reverse side of this form authorizes release of oral health information. This information may be protected from disclosure by federal privacy law and state law.
By signing this consent, I am authorizing oral health information to be given to the Board of Education of the City of New York (a/k/a New York City Department of Education) as well as school nurses and leaders, either because it is required by law or by Chancellor’s regulation, or because it is necessary to protect the health and safety of the student. Upon my request, the facility or person disclosing this oral health information must provide me with a copy of this form. Parents are required by law to provide certain information to the school, like proof of immunization. Failure to provide this information may result in the student being excluded from school.
My questions about this form have been answered. I understand that I do not have to allow release of my child’s oral health information, and that I can change my mind at any time and revoke my authorization by writing to the School-Based Oral Health Clinic. However, after a disclosure has been made, it cannot be revoked retroactively to cover information released prior to the revocation.
I authorize Smile New York Outreach, LLC School-Based Oral Health Clinic to release specific oral health information of the student named on the reverse page to the Board of Education of the City of New York (a/k/a New York City Department of Education).
I consent to the release from the School-Based Oral Health Clinic to the NYC Department of Education and from the NYC Department of Education to the School-Based Oral Health Clinic, of oral health information outlined below in order to meet regulatory requirements and ensure that the school has information needed to protect my child’s health and safety. I understand that this information will remain confidential in accordance with Federal and State law and Chancellor’s Regulations on confidentiality:
Information to Protect Health and Safety:
- Conditions which may require emergency
- Conditions which limit a student’s daily activity (Form 103S)
- Diagnosis of certain communicable diseases (not including HIV infection/STI and other confidential services protected by law).
- Health insurance coverage
My signature on page 1 of this form also gives my consent to Smile New York Outreach, LLC to contact other providers that have examined my child and to obtain insurance information.
Time Period During Which Release of Information is Authorized:
From: Date that form is signed on opposite page
To: Date that student is no longer enrolled in the School-Based Oral Health Clinic
*OHCP = Oral Health Clinic Provider
You Must Read and Agree to the Important Notice & Consent Statement Prior to Submitting
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