The above-named patient (student or employee) has consent to receive services offered by the Community Consolidated School District 21 (CCSD21) School Health Center, located at District 21 Community Service Center and Administrative Office (CSCAO) l, and its contracted provider, Advocate Health Care.  In providing informed consent, I understand that:

1. I/the student will receive any services provided by the CCSD21 School Health Care Center at no cost. 
2. I understand that a parent, legal guardian, or student who is permitted under Illinois law to consent on his or her own behalf has a right to refuse any health care services. 
3. Available services offered in the CCSD21  School Health Center will be similar to what community members can receive in a low-acuity immediate care center including, but not limited to:
   • School and sports physical examinations, immunizations, and COVID-19 testing and vaccinations;
   • Diagnosis and treatment of acute illness and injury;
   • Diagnosis and management of chronic illness;
   • Health education and promotion;
   • Wellness promotion including smoking cessation, nutrition, weight management;
   • Laboratory tests including throat cultures, complete blood counts, mono spots, etc.;
   • Individual or family sessions with a licensed clinical therapist;
4. No reproductive healthcare services will be provided.
5. If a service is requested or needed by the patient outside of the regular school day or outside of the scope of services offered by the CCSD21 School Health Center, Advocate Health Care will offer a referral.
6. Services provided by the CCSD21 School Health Center may be on-site and/or through telehealth communications if deemed appropriate by a clinician. 
7. Telehealth includes the practice of health care delivery, including mental health care delivery, evaluation, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications.  Telehealth may involve the communication of medical/mental health information, both orally and visually, to other healthcare professionals.
8. The services provided by the CCSD21 Student Health Center are not intended as primary care services and are not a substitute for parental/eligible student monitoring of the student’s health or regular visits to a primary care physician.
9. Confidentiality of all medical records will be maintained by the CCSD21 Student Health Center and Advocate Health Care as required under applicable federal and State laws and regulations, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA), Consent by Minors to Health Care Services Act, Illinois Mental Health and Developmental Disability Code, the Illinois Mental Health and Developmental Disability Confidentiality Act, and 77 Ill. Admin. Code Part 641.
10. The results of school and sports physical examinations and immunizations will be shared reciprocally with Community Consolidated School District 21.
11. Therapists have mandated reporters of child and elderly abuse and neglect under state law and are required to report any disclosed or suspected incidents of child or elderly abuse or neglect to the Illinois Department of Children and Family Services hotline in accordance with the Abuse and Neglect Child Reporting Act.
12. The CCSD21 Health Center staff is required to report to the IDHS FOID Mental Health Reporting System for persons that are determined to be a clear and present danger to themselves or others, or developmentally or intellectually disabled.
13. Should a patient present a risk of harm to themselves or another person, it may be necessary to disclose confidential information in an attempt to protect the patient or alert the person who is in danger of harm.  If suicide is a risk, as permitted by law, seek to hospitalize or contact a family member or others to help with protection.
14. To the extent permitted by law, our therapists share with parents any general progress reports for children and adolescents and will disclose to parents if the child/adolescent is in an emergency or is at risk for or is committing potentially dangerous or harmful behaviors.
15. In consideration for the student’s participation in the CCSD21 School Health Center and as evidenced by signature below, I hereby release and hold harmless Community Consolidated School District 21 and its Board of Education and administration, employees, agents, and representatives from any liability which may accrue to me and/or the student for any and all losses, injuries, or damages to me and/or the student, both known and unknown, foreseen and unforeseen, arising out of or in connection with the student’s participation in the CCSD21 School Health Center.
16. The patient will not receive services at the CCSD21 School Health Center unless a signed Consent form is on file.
17. I consent to the release of relevant health information and medical records in connection with treatments at the CCSD21 School Health Center and its collaborating partners to facilitate my child’s health needs.  I further authorize the CCSD21 School Health Center to release information regarding my child’s treatment to third-party payors or others for billing, program management, and evaluation in accordance with federal and state laws and regulations regarding confidentiality.
18. I further understand that under Illinois law, a minor over age 12 has the same capacity as an adult to consent to certain health services, and no parental permission is required for such services.
19. I understand that if my child is 12 or older they can receive mental health and substance abuse services at the CCSD21 School Health Center without my consent.  Per 405 ILCS 5/3-5A-105(a), they may receive up to eight 90-minute sessions for mental health services.  By law, a child under age 12 will not be allowed to receive mental health/substance abuse services without parental consent.
20. I understand that transportation from my child(s) school can be provided. 
21. The patient or their parent/legal guardian may revoke this consent or stop or refuse services at any time.  Revocation of consent will be provided in writing to the CCSD21 School Health Center director or health care provider.

AUTHORIZATION FOR RELEASE OF PERSONAL HEALTH INFORMATION: 

I authorize/allow the use and disclosure of this personal health information (PHI) for the purposes of diagnosing or providing treatment, obtaining payment for care, or for health care business management of Advocate Health Care. I authorize Advocate Health Care to provide my child’s educational institution/school with a copy of the health exam and to include immunizations administered. I authorize Advocate Health Care to release information from the visit to the primary health care provider/doctor. I have the right to inspect and receive a copy of the health information I have authorized to be disclosed by the Authorization. I am aware that I may revoke this Authorization by notifying Advocate Health Care or the school in writing.  I realize that the information disclosed pursuant to this Authorization may be subject to re-disclosure and no longer protected by federal privacy law.

By my signature below, I also authorize the Community Consolidated School District 21 and/or Advocate Aurora Health Care to release information to Medicaid, where applicable, for purposes of billing, in accordance with all federal and State laws and regulations.