School-Based Health Center (SBHC) Parent/Guardian/Student Consent for Student Health Care Services

Students may be asked to participate in a satisfaction survey and a health questionnaire every school year.

Agreement: Please read carefully and sign at the bottom.

Financial Responsibility: If you have payment concerns, please notify the billing department (541-618-4414). We will work with your insurance.

Insurance Authorization: I understand the financial policy above and accept financial responsibility. By signing below, I assign RCH all payments due from my insurance company for services rendered.

NO ONE IS TURNED AWAY FOR INABILITY TO PAY. Students will receive many services without a fee.

Medical Home
Rogue Community Health (RCH) has a model of care called a Patient Centered Medical Home. This means the clinic is my health care setting where I work in partnership with my care team to address all of my health care needs.

Release of Information: Do we have your permission to:

I authorize Rogue Community Health to use and disclose the health and medical information of the above named patient for the purposes of Treatment, Payment and Health Care Operations.

* Treatment (includes activities performed by a provider, nurse, lab personnel, office staff, arid other types of health care professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between other health care providers. This consent includes treatment provided by any medical personnel who covers our practice by telephone as the on-call medical personnel.
. Payment (includes activities involved in determining your eligibility for health plan coverage, billing and receiving payment for your health benefit claims, and utilization management activities which may include review of health care services for medical necessity, justification of charges, pre-certification and pre-authorization).
* HealthCare Operations (includes the necessary administrative and business functions of our office). Rogue Community Health is part of an organized health care arrangement including participants in the Oregon Community Health Information Network (OCHIN). Your health information may be shared by Rogue Community Health with other OCHIN participants when necessary for health care operations.

Because we have reserved the right to change our privacy practices in accordance with the law, the terms contained in the Notice may change also. A summary of the Notice will be posted in our waiting room and web site indicating the effective date of the Notice in the upper right hand corner. We will offer you a copy of the Notice on your first visit to us after the effective date of the then current Notice. We will also provide you with a copy of the Notice upon your request.

As more fully explained in the Notice, you have the right to request restrictions on how we use and disclose your protected health information for treatment, payment, and health care operations purposes. We are not required to agree to your request. If we do agree, we are required to comply with your request unless the information is needed to provide you emergency treatment. Other medical personnel who provide call coverage for our office are required to use and disclose your protected health information consistent with the Notice.

I understand that I have the right to revoke this CONSENT provided that I do so in writing, except to the extent that Rogue Community Health has already used or disclosed the information in reliance on this CONSENT.

Click here to view the Notice of Privacy Policy in English

Click here to view the Notice of Privacy Policy in Spanish