Dear Parent or Guardian: Our School Based Dental Program is pleased to provide the following services at your child’s school during school hours: dental cleaning, fluoride treatment, oral health education, sealant placement & restorative care (if needed). Please fill out this form and return to the school nurse to enroll your child in the program. Questions? Call our Coordinator at 860-528-1359 x183

Student Information
Insurance Information
Income
Last Dental Visit

Permission for Treatment, Payment and Operations

I give permission for my child to receive medical, dental, and behavioral health treatment services by First Choice Health Centers, Inc. I understand that this authorization is valid as long as my child is enrolled in the school district listed above or until I revoke this authorization with the Program Coordinator at First Choice. I hereby authorize First Choice to use and disclose my child's medical/dental information for treatment, payment and healthcare operation purposes. My consent includes the release of such information to process claims to my insurance company. I authorize direct payment from my insurance company to First Choice. I also allow disclosure of protected health information to the school nurse as appropriate. I consent to receiving phone calls regarding services my child receives or may be eligible to receive. I acknowledge that I have received a copy of the Notice for Privacy Practices for First Choice Health Centers, Inc., which further explains how First Choice may use and disclose my child’s Protected Health Information. By signing this consent form I certify I am the legal guardian and legal custodian of the student named above. I have read and understand the above and agree with the above paragraph and certify that all the information provided is true and correct. To better provide care, the Provider seeks to coordinate integrated delivery through the electronic health record, which is paperless. The information is shared across provider locations and may be shared with some other affiliates through a health information exchange.The Provider uses a system that allows electronic prescribing of medications. I authorize the Provider to request and use my child’s prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes. By signing this form, I understand and agree that I am allowing the disclosure and access to all my child’s health information, including information related to alcohol and substance abuse/use, mental or behavioral health, medication prescription history, and HIV/AIDS. I understand if I do not want my information stored in the electronic health record (which may be shared through health information exchanges), and utilized in my care, I will not be able to receive care with from the Provider, and have the right to opt out of receiving care at any time.


I certify and attest that all of the above information is true and correct. I understand that FCHC may verify information on this form. I understand that the financial information will determine eligibility for the center’s sliding fee discount. I also understand that if I intentionally misrepresent my family’s income, my child will not be eligible to receive services at a discounted rate. I also understand that I will be financially responsible for all charges incurred should insurance not cover the services.

Complete below section if child is less than 5 years old or if there was a significant/complicated pregnancy history
Diagnosis of relative Relationship to child
Diagnosis of relative Relationship to child

Child lives w/:

Complete below section if child is less than 5 years old or if there was a significant/complicated pregnancy history