Hope Family Health Center

2021-2022 School Based Health Center Consent Form

***Form must be complete and signed to be valid***

Please read the following statements and be sure that you understand each statement:

I give consent for my child to receive the services indicated in the box below in this document. By signing this consent, I certify that I am the legal guardian and legal custodian of the student listed below. I understand I may withdraw my consent at any time with written notice and I understand it is my responsibility to be sure the Health Center has received my withdrawal of consent. I understand that I will be asked to update this consent form yearly.

I authorize Hope Family Health Center to release information regarding treatment to other medical or mental health providers when needed for coordination of care, or to third party payers or others for purposes of receiving payment for services. I understand that Hope Family Health Center will bill insurance (when/if available) for services rendered. Telehealth visits are billable and Telehealth billing information is collected in the same manner as a regular office visit. I further authorize both the Health Center and my child’s primary care provider to exchange health care information for the purpose of continuity and coordination of care. I give permission to the Health Center to obtain a copy of my child’s immunization record from the MCIR, the school office or the local health department and make updates as needed. As recommended by the American Academy of Pediatrics, I understand that a routine general health and risk behavior screening will be provided by the Health Center.

I understand that testing for blood borne diseases, including HIV/AIDS may be performed upon a patient without a separate written consent in the event that a healthcare professional from the Center sustains exposure to blood or body fluids from the patient’s open wound, mucous membranes or occupational hazard.

I understand that as an entity of Detroit Wayne County Health Authority, the Hope Family Health Center participates in and recognizes the rules of the Health Information Portability and Accountability Act (HIPAA). In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or communications by alternative means such as to a cell phone instead of the home phone. I have received a copy of the Hope Family Health Center’s Notice of Privacy Practices.

The Hope Family Health Center is operated by Detroit Wayne County Health Authority and its Teaching Health Center program. I understand that my child will be seen and treated by pediatric and family medicine resident physicians under the direct supervision of the Center's pediatrician.


Sign Here

The Hope Family Health Center has a Telemedicine System. By signing the consent form, you are giving Health Center nursing staff permission to communicate and consult with a Detroit Wayne County Health Authority physician via Telehealth regarding your child’s medical condition on an as-needed basis with the understanding that this information will continue to be treated in a confidential manner. This includes telephone consultations, video conferencing, transmission of still images, e-health technologies, patient portals, texting, and email and involves the communication of patient medical/mental health information in an electronic or technology-assisted format. My child may also receive telehealth services in our homes.

Student Name: Grade:

Parent/guardian signature: Date:

Printed Name: Phone Number:

*Parent E-Mail Address:

*Optional: Will be used for School Based Health Center Listserv and Marketing Purposes ONLY

Parental consent is required for the following services provided the student/patient is under the age of 18:

Current Michigan Law allows for confidential services to minors in these areas without parental consent:

  • Well childcare, reproductive health information, preventive services

  • Physical exams for school and sports

  • Treatment for acute & chronic illness & injuries

  • Vision/hearing screenings and follow-up

  • Immunizations

  • Basic laboratory screening and on-site testing

  • Mental health services, including individual counseling & crisis intervention

  • Referrals for specialty services

  • Student health education & risk reduction programs

  • Pregnancy testing and referrals

  • Sexually transmitted disease screenings, treatment and counseling

  • HIV testing and referrals

  • Physical/sexual abuse counseling and referrals

  • Crisis Intervention

  • Substance abuse counseling and referrals

  • Mental health assessment, counseling and referrals at age 14 years and above

Parental consent is not required for crisis intervention and emergency care.

Current Michigan Law PROHIBITS Hope Family Health Center from:

Distributing or prescribing birth control pills or devices or giving abortion counseling/referral information.

Hope Family Health Center is sponsored by Detroit Wayne County Health Authority with funding from the Michigan Department of Community Health, and the Michigan Department of Education.

Updated 09/2021