Occasionally student may receive over-the-counter (OTC) medication (such as Tylenol, ibuprofen, etc.) at the SBHC. However, students with daily needs for OTC while at school will need to complete D9’s form “Medication – as needed (EPSD 03122020)” or Self-Medication Carry Agreement.

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

Consent for Treatment: I consent to treatment necessary for the care of the above-named patient. I authorize release of all medical records to referring healthcare providers and to my insurance company, if applicable. I authorize fax transmittal and/or HIPAA secure electronic submission of my medical record, if necessary.

Financial Responsibility: All insurance co-pays are due at the time of the visit. All patients with self-pay accounts must bring cash payment at each visit. Patients that have made payment arrangements and/or received a monthly statement must make a payment within thirty days of the statement date. We will bill your insurance for you. However, your account remains your responsibility. If you have payment concerns, please notify the billing department (541-618-4414).

No student will be turned away for inability to pay

Insurance Authorization: I understand the financial policy above and accept financial responsibility. By this agreement, I assign Rogue Community Health all payments due from my insurance company for services rendered.

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

Communication: Do we have permission to:

I have read and fully understand the above consent for treatment, financial responsibility, release of medical information, and insurance authorization. These agreements will remain in effect for the life of the student while enrolled in school for Medical services and for approximately 12 months for BH services, or until revoked by me in writing, by submitting it to compliance@roguch.org. If revoked, I understand the authorization will not affect any use or disclosure of information that has already occurred.

*Treatment includes services performed by a provider, nurse, lab personnel, office staff, and other types of healthcare professionals providing care to you, coordinating or managing your care with third parties, and consultations with and between other healthcare 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 of services. 

*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 healthcare operations. 

*Communications As a patient of Rogue Community Health, you may be contacted via text or voice messaging to remind you of an appointment, to obtain feedback on your healthcare experience with our medical, dental and/or behavioral health teams, and to provide general reminders.  I consent to receiving appointment reminders and other healthcare communications via text or voice message from Rogue Community Health at my preferred telephone number and any number forwarded or transferred to that number.  I understand that this request to receive text or voice messages will apply to all future appointment reminders/feedback/health information.  I further understand that message/data rates may apply to “sent” messages under my cell phone plan.

Rogue Community Health reserves the right to change our privacy practices in accordance with the law which may change the terms contained in the Notice.  A summary of the Notice is posted in our waiting room and on our website (www.roguecommunityhealth.org) and includes the effective date of the Notice in the upper righthand corner.  We will offer you a copy of the Notice on your first visit to us after the effective date of the most 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 purposes of treatment, payment, and healthcare operations.  We are not required to agree to your request.  If we do agree with your request, we are required to comply with your request unless the restricted 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 agree to the terms stated herein and understand that I have the right to revoke this CONSENT provided I do so in writing to the Compliance Director at compliance@roguech.org, except to the extent that Rogue Community Health has already used or disclosed the information based on this CONSENT.