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वाइकिंग स्कूल-आधारित स्वास्थ्य केन्द्र बिरामी नामांकन 

If you prefer to fill out the enrollment form and consent form by hand, please print off this document and return the completed forms to the

Mt. Healthy School Based Health Center.

Consent Form

Consent for SBHC Services: 


I, the parent/guardian of said student, give consent for my child to receive services at the School-Based Health Center (SBHC) operated by The HealthCare Connection (THCC). I authorize THCC to provide medical, dental, and behavioral health services. Dental treatment includes the application of fluoride varnish to your students’ teeth. Fluoride varnish is an American Dental Association accepted therapy that can reduce dental decay by up to 33%. It is a non-invasive, 20 second treatment. All health care information is confidential. By signing the consent form, I am giving SBHC staff, the school nurse, and my child’s regular medical provider (if applicable) permission to communicate and share medical information regarding my child’s medical condition on an as needed basis with the understanding that this information will continue to be treated in a confidential manner. Confidentiality between the student, parents and SBHC is assured. I do understand by law, some information requires the student’s signed consent prior to disclosure to anyone, including parents & guardians; and that SBHC staff will encourage every student to involve his/her parent/guardian in health care decisions. I also understand that by providing an alternative contact, if I cannot be reached, medical information regarding the above-named child will be shared between the SBHC and the alternative contact. By signing this consent, I understand and agree to the terms and conditions regarding sharing of health information.

Fluoride Varnish Consent



I understand there is a charge depending on the service provided and that I will be responsible for payment. When available, my insurance including Medicaid will be billed. The SBHC may release information regarding treatment to third party payers for billing purposes. I understand no student will be denied access to SBHC medical services due to inability to pay.

Health Information Release:


I understand and agree that my health information may be stored in or released through one or more electronic health records systems through which healthcare professionals and facilities and others involved in my care may view and obtain information. I also understand and agree that, once my health information is released in that way, it may be added into other treating providers’ medical records and be aggregated with the health information of others and used or disclosed to conduct data analysis, or for any other lawful purpose. I understand that this Health Information Release Consent applies to information generated prior to the date of this consent and during any subsequent visit while this consent is in effect. This consent is effective on the date of my signature (or the signature of my authorized representative) below. I may revoke this consent in writing, at any time; provided, however, that such revocation will not apply to any uses or sharing of my heath information that occurred prior to the date the written revocation was received.

Acknowledgement of Notice of Privacy Practices:


I have received a copy of the Notice of Privacy Practices. This Notice describes how my health information may be used or disclosed. I understand that I should read it carefully. Within this Notice of Privacy Practices is contained a complete description of my privacy/confidentiality rights. I am aware that the Notice may be changed at any time. I was given the opportunity to review the Notice and ask questions regarding my privacy rights. I understand that by law, THCC may use or disclose specific information without authorization. Those specific reasons are listed in the Notice. I further understand that my medical information is protected under HIPAA for privacy and confidentiality and cannot be released without my written consent. By signing this form, I am authorizing THCC’s use and disclosure of my protected health information as detailed above. However, I may give notice to restrict the use of such information and revoke my consent in writing.

Thank you for submitting!

Enrollment Form - Mt. Healthy School Based Health Center

Patient Details

Health Care Services Needed (Check all that apply)
Child's Insurance Information (Check all that apply)

Parent/Guardian Contact Information

Okay to email in non-emergency situations?
Can we leave a message? (Check all that apply)
Relationship to Student

Alternate Contact Information

Okay to email in non-emergency situations?
Can we leave a message? (Check all that apply)
May we send them infomation?

Student's Health Provider Information

Physical Exam Needed

General Information:


We accept most commercial insurances, Medicaid, and managed care plans, and offer discounts to families based on income and family size. For more information about discounted services, or to apply, parents should call The HealthCare Connection’s (THCC) Finance Department at 513-483-3078. No student is denied services due to the inability to pay. Staff members are available to assist families without insurance to determine eligibility for Medicaid or the federal health exchange. For more information or to request assistance, parents should call 513-483-3071 to speak with a Resource Advocate.

Student Health History

Does your child hve any of hefllowngmedical problems? (Chec all tat apply)
Family Medical History (Check all that apply)

Thanks for submitting!

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