Bysigning below as the authorized representative ¹ (legal guardian or approved minor or adult student), I consent for the student to receive services at Lowell Community Health Center's (LCHC) School-Based Health Centers (SBHC I give permission for a designated health provider to deliver services which may include: Physical Health, Behavioral Health, Vision and Nutrition exams, assessments and screenings, immunizations, and general management of their health care. The health record of students seen at the SBHC is a confidential record, and is not part of a school record. I understand that confidentiality will be observed due to the nature of this type of record. I also authorize LCHC to release information regarding treatment to third party payers for billing purposes and for any reason required by statues and regulations described in LCHC's Notice of Privacy Practices. For the purpose of continuity of quality care and when relevant to treatment, I hereby authorize the exchange of information2 between Lowell Community Health Center and the entities listed below: Lowell Public Schools Lowell Community Health CenterPrimary Care Doctor Attendance & Behavior Health History Health History Treatment Progress Treatment Progress Substance Use504 Plan or IEPSubstance Use
2Psychotherapy notes, genetic testing, and HIV testing must be requested specifically and separately. Further disclosure is prohibited without written consent by the student or otherwise permitted by 42 CFR Part 2.
Ihave read and understand that authorizing the exchange of health information is voluntary and not conditional to
receiving treatment. | understand this consent is subject to revocation made in writing at any time, except to the extent that disclosure made in good faith has already occurred. Information released may be subject to re-disclosure by the recipient. This consent and authorization will expire following withdrawal or graduation from Lowell Public Schools.