To Parent(s) and/or Guardian(s):

     Monroe Health Center will once again open our Wellness Centers in the upcoming 2012-2013 school year. They are currently located at Mountain View Elementary/Middle School, Peterstown Elementary/Middle School and James Monroe High School.
 
    The Wellness Center gives your child an opportunity to be seen by a licensed health care provider without having to miss a lot of school time. An explanation of services offered by the Wellness Center is listed below.  You do not have to be present for your child to be seen however a consent form must be signed by you in order for any services to be rendered.  Thanks and hope you have a happy & health school year!

Description of Services

•	Preventative Medicine Services such as Well Child Physicals & Immunizations.  
•	Sports Physicals, Allergy Injections, Prescriptions, Lab Testing, Referrals & Follow-up Care.
•	Care for Acute Illness, Minor Injuries & Chronic Conditions. 
•	Mental Health Counseling (example coping skills, stress/anger management, depression, anxiety).  
•	Family Planning Services including abstinence education, birth control and STD prevention.
•	Administration of medication for minor health problems as appropriate per Board of Education Standing Order Policy.   
     If you do not have insurance, there will be no cost for services. If you do have insurance, it will be billed when the child is seen. The co-pay and any deductible for students will be waived.  If you have any questions or concerns please contact us at any of the following numbers.   

Staff, Contact Information & Hours

     Our staff is here to assist you and we are available to communicate with the parents of each child. We want to know your concerns and be able to keep you updated on your child’s health. Feel free to contact us during office hours. The Wellness Center works with, and is not meant to replace, your family doctor and/or school nurse.  

Our staff includes:      Dr. Sophia Sibold, DO, Wellness Center Director                          Emily Adkins, LPN
                                    Tambra Pitt – FNP-BC                                                                    Stephanie Darnell, LPN
                                    Nancy Lynch –FNP-BC                                                                   Kim Rhodes, LPN

Mountain View Wellness Center 	          Peterstown Wellness Center 	         James Monroe Wellness Center
620 School Street                                         108 College Drive                              Route 1, Box 97-1-A              Union, WV  24983                                       Peterstown, WV  24963                     Lindside, WV  24951        Phone:  (304) 772-4580                                Phone:  (304) 753-6960                     Phone:  (304) 753-5940                    Fax:  (304) 772-4581                                    Fax:  (304) 753-6961                         Fax:  (304) 753-5941
Hours:  Monday – Friday                             Hours:  Monday – Friday                   Hours:  Monday – Friday
8AM-11:30AM                                            8AM-11:30AM                                  12:30PM-4PM

PLEASE SEE OTHER SIDE

After hours number 1-866-834-6531

                                                                                                                         
ENROLLMENT & CONSENT FORM
2012-2013 SCHOOL YEAR 

STUDENT INFORMATION 
                                                                                                                                                                         Student Name:  __________________________ Gender:  M or F Date of Birth:  ___________   Grade:  _____   
Address:  ___________________________________ City/State/Zip/County:  ___________________________ Student SS#:  ___________________ Email:  _________________________________Cell:_______________
Race:  White, Black or Other ______ Ethnicity:  Latino or Other ______ Language: English, Spanish or Other ________

PARENT / GUARDIAN INFORMATION/EMERGENCY CONTACT
Father:  _______________________Phone (H) ___________________ (W) __________________(C) _______________ 
Mother:  ______________________Phone (H) ___________________ (W) __________________(C) _______________
Guardian:  _____________________Phone (H) ___________________ (W) __________________(C) _______________
Alternate Contact: ________________________Phone (H) ________________ (W) _____________(C) _____________

                                                                    HEALTH INFORMATION
1.	List any allergies your child may have and any medications your child should not take: ________________
2.	List any medications your child currently takes and why:  ________________________________________
3.	Family Physician/Pediatrician:  _____________________ or None  Dentist:   ________________________
4.	If we need to call in a prescription, which pharmacy would you like us to call?  _______________________
5.	Please initial if you would like your child to have a physical exam completed at the Wellness Center: _____
6.	Medical History _________________________, Surgical History _________________________________
7.	Hospitalizations__________________________, Special Needs ___________________________________
 
INSURANCE - Please provide a copy of your current Insurance Card if not available fill out information below

INSURANCE:  	   Name of Insurance Company:  _________________________________________ 
Please fill out                Address:  __________________________________________________________ 
         Information or             City/State/Zip Code:  ___________________ Insurance Phone #:   ____________
         Provide copy of            Policy/ID #:  ________________________ Group #:  ______________________
         Card front & back       Policy Holder Name:  _____________________ Date of Birth:  ______________
				Policy Holder SSN#:  ________________ Place of Employment:  ____________

MEDICAID:  Please Check One                                          Unisys           Unicare             Carelink    

                                                          ID#_____________________ Group #_________________________
WV CHIPS:  ID#_________________________________

No Health Insurance/Request Application for Sliding Scale Fee/CHIPS/Medicaid   
        Gross Monthly Income:  ________________       Number in Household:  ________________________

PLEASE SEE OTHER SIDE

                                                                                 Student’s name:  __________________________________

CONSENT FOR WELLNESS CENTER SERVICES 
 I, the parent/guardian of said student, give consent for my child to receive all services at the Wellness Center.  I understand that this consent form is valid for the entire school year while my child is enrolled or until I provide the Wellness Center staff with written directions otherwise. 
All healthcare information is confidential.  By signing the consent form you are giving the Wellness Center, school nurse and your child’s regular doctor (if applicable) permission to communicate and share medical information 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. No student will be denied access to health care services due to inability to pay.  As in any health center, there may be a charge depending on the service provided.  When available, insurance or Medicaid will be billed. The health center may release information regarding treatment to third party payors for billing purposes. 
Confidentiality between the student, parents and the health center is assured.  By law, some information requires the student’s signed consent prior to disclosure to anyone, including parents/guardians.  The staff will encourage every student to involve his/her parent/guardian in health care decisions.  I am the legal guardian of the above named child.  I understand that if guardianship changes a new consent must be signed by the legal guardian. I also understand that by providing an alternative contact, if I cannot be reached, medical information regarding the above named child will be shared between the medical provider and the alternative contact.    

			_________________               _                                                                                                                       Signature of Parent / Legal Guardian		             Staff Signature                                             Date      

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires all physicians and health care facilities to provide patients with a notice describing how an individual’s medical information may be used and disclosed, and how a patient may obtain access to their personal health information.  
Please note that a copy of this policy is located at the Wellness Center, can be obtained from our sponsoring center’s web site www.monroehealthcenter.com or can be mailed to you at your request. You must sign below, indicating that you have received notification on how to obtain a copy of our HIPAA policies, prior to the student receiving services.   
_______________________________			____________________
Signature of Parent/Guardian					Date   
_______________________________			____________________

PLEASE SEE OTHER SIDE

Signature of Staff				                        Date