New Haven Public Schools
School Health Centers
PARENT PERMISSION FORM
DENTAL SERVICES

New Haven Public Schools
School Health Centers
PARENT PERMISSION FORM
DENTAL SERVICES

Dear Parent/Guardian: New Haven Public Schools (NHPS) is very pleased to offer dental services to students in your child’s school. Our Dental Hygienists will provide these services during school hours:

  • Screenings/Exams
  • Dental Sealants and Oral Health Education
  • Cleanings
  • X-rays and intra/extra oral photos
  • Referrals
  • Fluoride treatments
  • Emergency care
  • Fillings and simple extraction (loose baby teeth)

Instructions: Please fill out ALL the following information and submit, if you would like your child to be eligible for these services. We will bill your insurance company as we do for any SHC service, and there will be no cost to you. Please fill out one form per child.

Student and Parent / Guardian Information

school
First
Last
Address
Address
City
State/Province
Zip/Postal
Primary Home Address
Primary Home Address
City
State/Province
Zip/Postal
Who lives with Student (check all that apply)

Emergency Contact

Medicaid or Husky Insurance / Private / Commercial Insurance

Type of Insurance (check all that apply and complete information below on your child’s insurance coverage) *

Medicaid or Husky Insurance

Private / Commercial Insurance

Policy Holder’s Address
Policy Holder’s Address
City
State/Province
Zip/Postal
Address
Address
City
State/Province
Zip/Postal
Address
Address
City
State/Province
Zip/Postal

--

Child has Primary Health Provider:
Address
Address
City
State/Province
Zip/Postal

Does your child have a history of one of the following

If you DO NOT want your child to receive certain dental services, please select from the services below”
PERMISSION FOR TREATMENT

You have my permission to do the dental treatment my child needs listed on the top of this form excluding services selected above. I will be notified if my child needs additional dental treatment not available at my child’s school. I give permission for the dentist to use local anesthesia (i.e. lidocaine) if it is needed to “numb” the tooth. I also give permission to release information regarding treatment and/or services to insurance providers for the purpose of billing, and authorize payments to be made directly to New Haven Public Schools.

I authorize my child’s dental information to be shared with Richard Del Vecchio, D.D.S. (our dentist) for x-ray interpretation and/or to your child’s dentist (at your request), and for the Dental Staff to communicate with key school staff about relevant health issues to ensure that the best quality of dental care is provided to your child.

NEW HAVEN SCHOOL-BASED HEALTH CENTERS

PRIVACY NOTICE

According to federal law, we are giving you this Notice of Privacy Practices. It describes how we may use and share your child’s protected health information (PHI). If you are 18 years old or older or an emancipated minor, ‘your child’ refers to you. It also describes your rights to access your child’s PHI. “Protected Health Information” (PHI) is information about your child, including demographic information that may identify your child and that, in any way, relates to your child’s physical or mental health

PLEASE READ THIS NOTICE CAREFULLY.

New Haven School-Based Health Centers (SBHCs) are committed to respecting your and your child's privacy. Therefore, we are required to abide by the terms of this Privacy Notice. We may change the terms of this notice at any time. Updates/revisions will be posted in your child's health care provider's office. Copies will be available upon your request.

How We Will Use and Disclose Your Child's PHI with Your Signed SBHC Consent

Once you sign the SBHC Permission Form, we will provide direct medical/mental health care to your child, even if you are not present at the time we see your child for services. After the permission form is signed, we may share your child’s PHI in order to carry out treatment, payment and/or healthcare operations. Here are some specific examples of how we will share your child’s PHI.

Treatment: In order to ensure the highest quality of service for your child, we will use and share your child's PHI to provide, coordinate or manage your child's medical/mental health care. We will share only information that is necessary for your child's health and welfare. We may share PHI with other providers/clinics that contribute medical/mental health care to your child located within or outside the school. Examples of providers include but are not limited to school nurse, nurse practitioners, medical doctors, social workers, dentists, professional counselors, outreach workers and medical assistants. Furthermore, the SBHC may need to exchange information with a representative(s) of the New Haven Public Schools. We may also use and share your child's PHI with a member of your family, a relative, a close friend or any other person you identify on your child's SBHC Permission Form. This will include notifying people identified as an emergency contact on your child's consent form. In addition, during a parent guidance or family counseling session, we may disclose your child's PHI to you and those present.

Payment: Your child's PHI will be used and shared to obtain payment for health care services if you have insurance. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services. In addition, we may use and share your child’s PHI to help you and/or your family to obtain medical insurance (such as HUSKY) and services from other social service agencies.

Healthcare Operations: In order to ensure the highest quality of service possible to your child, we may use and share your child's PHI in order to support the business activities of the clinic. These activities include, but are not limited to, quality assessment activities, employee review activities, supervision of employees, training of students, and licensing. We will send a pass to your child's teacher for your child to come to the clinic for an appointment. We may call your child by name over the school's intercom system to come to the clinic. We may telephone you to remind you of your child's appointment. Furthermore, we will share your child's PHI with third party "business associates" necessary to perform various activities for the clinic. Whenever an arrangement between our office and a business associate involves using or sharing your child's PHI, we will have a written contract that contains terms that will protect the privacy of your child's PHI. Only relevant information that is necessary for the business associate to perform its duties will be shared.

The above examples are not inclusive of all the activities related to payment, operations and treatment. Other activities NOT related to payment, treatment, and operations will require that you give us written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time.

Other Ways We May Use or Disclose Your Child's PHI with Your Written Authorization or Opportunity to Object

We may use and share your child's PHI with your written authorization or opportunity to object in the following instances. If you are not present or able to agree or object to the use of the PHI, then your child's provider may, using professional judgment, determine whether the disclosure is in your child's best interest. In this case, only the minimal necessary PHI that is relevant to your child's health care will be disclosed.

Communication Barriers: We may use and share your child's PHI if a provider or other staff member in the clinic attempts to obtain consent from you but is unable to do so due to substantial communication barriers. If the provider determines, using professional judgment, that you intend to consent to the use of your child's PHI, the provider will do so. In order to serve you better, we may engage the aid of interpreters when a language barrier exists.

Potentially Harmful Activity: You may request, in writing, that a SBHC site will not release yours or your child’s PHI to a particular individual/agency if you believe such a disclosure may result in potential harm to you or your family’s safety.

Outside Referrals: We will require a written authorization to release your child’s PHI to a third party i.e.: community medical/mental health provider or an agency in which there has been no previous or current relationship.

Emergency Treatment: We may use or share your child's PHI in an emergency treatment situation. We will try to obtain your consent as soon as reasonably practical after the delivery of treatment. If your provider or another health care provider in the clinic is required by law to treat your child and the provider is unable to obtain your consent, he or she may use or share your child's PHI in order to provide a high quality of emergency care.

How We Will Use or Disclose PHI without Your Consent, Without Written Authorization or Without Opportunity to Object

The following are examples of other ways we may use and share your child's PHI without your consent, written authorization or opportunity to object. These are some examples in which we are required by law to share your child's PHI.

Required by Law: We may use or share your child's PHI, if the law requires it. The use of your child's PHI will be made in compliance with the law and will be limited to relevant requirements of the law. You will be notified, as required by law, if we use and share your child's PHI in this way.

Public Health: We may share your child's PHI for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability.

Communicable Diseases: We may share your child's PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may share your child's PHI with a health oversight agency for activities authorized by law, such as audits, investigations and inspections.

Abuse or Neglect: We may share your child's PHI with a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, if we suspect that your child may have been a victim of abuse, neglect or domestic violence we may share your child's PHI with the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may share your child's PHI with a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products to enable product recalls, to make repairs or replacements or to conduct post marketing surveillance as required.

Legal Proceedings: We may share your child's PHI in the course of a judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also share your child's PHI for law enforcement purposes.

Research: We may share your child's PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of the PHI.

Harmful or Self-Harmful Activity: Consistent with applicable federal and state laws, we may share your child's PHI, if we suspect that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of your child or another person or the public. For example, if your child threatens to hurt himself or herself or someone else, to commit suicide or homicide, or damage someone’s property, we may disclose his/her PHI to the appropriate parties, including New Haven Board of Education authorities.

Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

Your Rights:

The following is a statement of your rights with respect to your child's PHI and a brief description of how you may exercise these rights.

You have the right to inspect and copy your child's PHI, as per our protocol, which is contained in a designated record set for as long as we maintain the record. If your child is 18 years or older or an emancipated minor, he/she is considered an adult and you (the parent or guardian) do not have the right to inspect and/or copy their record.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and PHI that is subject to law and prohibits access to PHI of minors especially with respect to reproductive health, sexually transmitted infections, and drug or alcohol abuse/treatment.

You need to place this request in writing and the SBHC has 30 days to respond to this request, unless the PHI is not located on the site, then SBHC has 60 days to respond. The SBHC may ask for one extension of 30 days, and will provide you with a written statement of reasons for the delay and date of completion.

The SBHC has the right to deny a request if it is deemed the release of this PHI will likely endanger the life or safety of the individual or indirectly harm others mentioned in this PHI. The SBHC will provide a written statement of any denials.

You have the right to request a restriction on uses/disclosures of your child's PHI. This means you may ask us not to use or disclose any part of your child's PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your child's PHI not be disclosed to family members or friends who may be involved in your child's care or for notification purposes as described in this Privacy Notice. Your request must be in writing and state the specific restriction requested, to whom you want the restriction to apply, and the timeframe of the restriction. You may withdraw a restriction for disclosure in writing at any time.

Your provider is not required to agree to a restriction that you may request. If the provider believes, it is in your child's best interest to permit use and disclosure of their PHI, your child's PHI will not be restricted. If your provider does agree to the requested restriction, we may not use or disclose your child's PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restrictions you wish to request with your provider or clinic staff.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. Please make this request in writing to our Privacy Officer or clinic staff.

You may have the right to have your provider amend your child's PHI. This means you may request, in writing, an amendment of PHI about your child in a designated record set for as long as we maintain this information. The SBHC has to respond to this request within 60 days. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your child's medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your child's PHI. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Privacy Notice. It excludes disclosures we may have made to you, for a facility directory, to a family member or friends involved in your child's care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003 and for the next six years. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions, and limitations outlined in SBHC’s policy and procedure guidelines. Please contact the SBHC Privacy Officer for further details.

ALL SERVICES ARE AVAILABLE TO ENROLLED STUDENTS REGARDLESS OF THEIR ABILITY TO PAY OR INSURANCE COVERAGE

QUESTIONS OR COMPLAINTS

You may file a complaint to our Privacy Officer or the Secretary of Health and Human Services if you believe the privacy rights of your child have been violated. We will not retaliate against you or your child for filing a complaint. Please contact your child’s SHC site or the Privacy Officer at (203) 946-4860, if you have any questions regarding this Privacy Notice.