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:

• 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.
• Available services offered in the CCSD21 School Health Center will be similar what community members can receive in a low-acuity immediate care center including, but not limited to:
  
  • School and sports physical examinations, immunizations, and laboratory testing;
  • Diagnosis and treatment of acute illness and injury;
  • Health education and promotion
  • Individual or family sessions with a licensed clinical therapist
• 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.
• Services provided by the CCSD21 School Health Center may be on-site and/or through telehealth communications if deemed appropriate by a clinician.
• 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.
• 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.
• 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.
• The results of school and sports physical examinations and immunizations will be shared reciprocally with Community Consolidated School District 21.
• All health center providers are 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.
• 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.
• 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.
• To the extent permitted by law, our health center providers 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.
• 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.
• The patient will not receive services at the CCSD21 School Health Center unless a signed consent form is on file.
• 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.
• The health center considers parental involvement to be extremely important. We encourage all students to involve their parents or guardians in healthcare decision making. I understand that if my child is 12 or older, they can receive mental health and reproductive health 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/reproductive health services without parental consent.

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.