This General Consent Form is for CHISD Students Only:
Family Circle of Care (FCC) is offering health services on site at the FCC-Chapel Hill Clinic on the high school campus, 13172 State Highway 64E, Suite 8, Tyler, TX to CHISD students after completion of this consent form.
All Other Patients:
Parents, guardians, family members of students, CHISD staff, family members of CHISD staff and all community members may also receive services after completing a separate consent form available at the FCC clinic at Chapel Hill High School, as well as on the website, www.tylercircleofcare.org.
Services Offered
Services include diagnosis and treatment of illness and injury, mental health counseling and referrals, follow-up and potential referral for serious illness or injury. Services may also include, but are not limited to:
• Well child checkups
• sick visits
• Vaccinations
• chronic illness management (diabetes, asthma, etc.)
• athletic physicals
• lab services and diagnostic testing
• nutritional health education and counseling
• individual counseling and groups
Understanding Our Program
By signing this Consent for Treatment, you understand and agree that:
• FCC providers may provide services of the type listed above to your student.
• These services will be provided at FCC-Chapel Hill Clinic. Certain procedures may require you to sign separate, more specific consent forms.
• Reproductive healthcare services, including pregnancy prevention and testing, and testing and treatment of STIs are available at FCC-Chapel Hill Clinic with additional parental consents.
• FCC services are provided by FCC clinical staff and not CHISD employees.
• FCC does not provide emergency medical care; your student will need to visit a facility equipped to treat medical emergencies if there is a medical emergency.
• In order to provide medical, or mental health treatment of a minor child (below 18 years of age) without a parent or guardian present, this authorization must be signed prior to the first appointment.
• After submission of this form, a representative from FCC will contact me to answer any questions and discuss any additional forms that need to be completed.
• You may call (903) 535-9041 for an appointment. We recommend calling ahead for any planned appointments. Additionally, if your student gets sick during the day, he/she may come to the clinic for a same day appointment without an appointment.
• You may receive automated reminder telephone calls for appointments.
• I understand that FCC will attempt to call me before the appointment to confirm my consent and invite me to participate in the care and treatment of my student. I understand that if I or any of the adults listed below do not answer, my student may not be seen.
Acknowledgements
• I acknowledge that I am the parent or legal guardian authorized to make medical decisions for the minor child named above.
• I acknowledge that FCC will maintain an electronic health record in EPIC for all services provided for my student and that EPIC may be accessed by other healthcare providers and hospitals.
• I acknowledge that FCC may share medical records for purposes authorized by HIPAA, as set forth on the HIPAA privacy notice , which I acknowledge I have reviewed and understand.
• I acknowledge that I have reviewed and agree to comply with FCC’s Patient Rights and Responsibilities.
• I authorize and direct FCC to bill and collect payment from any insurance or other third-party payer that covers the services provided to my child.
• If I have health insurance, I acknowledge that it is my responsibility to verify that FCC is in network with my insurance carrier.
• I acknowledge that FCC accepts Medicaid and all major insurances, as well as offers a Sliding Fee Scale Discount Program, which may result in a reduced visit payment of $15, $20, $25, or $30 per visit for uninsured or underinsured patients.
