Did You Know?

North Country Children’s Clinic
2011-2012
Did You Know?
Your child can get health care services
in school at
NO cost to you!
Fill out the School-Based Health Center Enrollment Packet Today!
Treatment for illness and injuries, physical exams, dental care, and even counseling are all
available to your child at North Country Children’s Clinic’s school-based health centers. This
packet contains the paperwork you need to complete to enroll your child in the school-based
health center offered to all students enrolled in the Watertown City School District. Thank you
for taking the time to fill out and return one set of forms for each child being enrolled.
Enrollment information must be entered and then updated each school year.

Please complete the enrollment form (front & back), the yellow HIPAA form, and the
request to obtain information form.

Please remember to sign and date all forms.

If you have health insurance, please attach a copy of both sides of your health insurance
card.

When you have finished, please return the forms to your child’s homeroom teacher.
.
QUESTIONS? Please see the facts on the back for more information about the
school-based health centers offered to
Watertown City School District students.
North Elementary
SBHC
Wiley Intermediate
SBHC
Case Middle
SBHC
Watertown High
SBHC
Serves all elementary
students in WCSD.
Serves all students at
Wiley Intermediate.
Serves all students at
Case Middle.
Serves all students at
Watertown High.
Phone: 315-786-1767
Fax: 315-786-1856
Phone: 315-785-3783
Fax: 315-661-4003
Phone: 315-785-3809
Fax: 315-785-3818
Phone: 315-785-3703
Fax: 315-785-3807
North Country Children’s Clinic
2011-2012
School-Based Health Center Facts
Any student attending Watertown City School District can enroll in the school-based health centers.
 There are no eligibility or income requirements.
 A student can be enrolled in the school-based health center and keep their regular doctor.
 The school-based health center will always send copies of visits to your child’s regular provider.
You can enroll your child and use the school-based health center as your child’s doctor if your child does
not have one.
 North Country Children’s Clinic would be pleased to become your child’s regular medical provider.
When the school-based health center is not open you can use the services of our Primary Care
Clinic located at 238 Arsenal Street in Watertown.
If you have a regular doctor and cannot get an appointment you can use the school-based health center
instead of an urgent care or the emergency room.
 You can call the school-based health center for a same-day appointment even if your child is too ill
to attend school. Copies of your child’s visit will always be sent to your child’s regular doctor.
Services are provided at no out of pocket costs.
 If you have insurance the school-based health center will bill your insurance; if you don’t have
insurance there is no cost to your family. The health center can help your family to enroll in Child
Health Plus and/or Medicaid. Please note: the cost of services provided outside of the school-based
health center, such as laboratory tests, X-rays, specialty consultations, and prescriptions are the
responsibility of the parent.
Parents are always welcome to come to their child’s appointment at the school-based health center.
 However, if you have trouble getting time off of work or cannot attend the appointment we can see
your child during the school day and call you before and after their appointment.
The role of the school nurse has not changed.
 If your child becomes ill during the day, they will still go to the nurse’s office and the nurse will
call you. The nurse will ask you if you want your child to be seen at the school-based health center.
You do not have to use the school-based health center if you enroll.
 All parents are encouraged to enroll their child in the program as it is a service offered by the
school and can be used in acute situations. Signing an enrollment form does not mean that your
child has to use the services of the school-based health center.
The health center provides complete primary care such as physical exams, vaccinations, allergy shots,
treatment of illnesses such as ear infections or strep throat, and mental health counseling.
 If you would like to schedule an appointment (medical or mental health counseling) or if you have
any questions, please call the school-based health center (numbers are located on the front page).
2011-2012
SCHOOL-BASED HEALTH PROGRAM ENROLLMENT FORM
Student’s Birthdate:
/
/
Student’s Gender: M
Student’s Last Name:
Student’s Social Security Number:
First:
Student’s School:
Race:
F
/
/
Full Middle:
Grade:
Classroom/Homeroom Teacher:
Ethnicity:
White/Caucasian
Black/African American
Asian
Native Hawaiian/other Pacific Islander
American Indian/Alaskan Native
More than one race
Other
Hispanic or Latino
Non-Hispanic or non-Latino
Please check one box below that best fits your needs:
My child regularly goes to another doctor. I would like to use North Country
Children’s Clinic’s school-based health center when necessary. I understand that Doctor’s Office Name:
my child’s health care provider will receive reports following visits.
Last Seen On:
/
/
Last Physical On:
/
/
My child goes to the North Country Children’s Clinic (either the school-based health center or the Primary Care Clinic at 238 Arsenal Street).
My child does not have a regular doctor or clinic and I would like to use North Country Children’s Clinic’s school-based health center and the
Primary Care Center located at 238 Arsenal Street for my child’s healthcare needs.
All students who use the school-based health center are required by New York State to have an annual physical exam.
If your child is in need of a physical exam, FDOOWKHKHDOWKFHQWHUQXPEHUVOLVWHGRQWKHILUVWSDJHRIWKLVGRFXPHQW.
If your child has had a physical exam within the last year, please send a copy of that physical exam to the school-based health center.
Parent/Guardian Contact Information:
Parent/Guardian
Name:
Parent/Guardian
Name:
Mailing Address:
Mailing Address:
Home Phone:
Cell Phone:
Is it okay to leave a message or voicemail?
Home Phone:
YES
NO
Employer:
YES
NO
Employer:
Work Phone:
Work Phone:
Social Security #:
Relationship to
Student:
Cell Phone:
Is it okay to leave a message or voicemail?
/
DOB:
/
Mother
Guardian
/
/
Social Security #:
Father
Step-parent
Other __________________
Email Address:
/
/
Mother
Guardian
Relationship to
Student:
DOB:
/
/
Father
Step-parent
Other __________________
Email Address:
Is it okay to email in non-emergency situations?
YES
Who may make
medical decisions for
this student?
Mother
Father
Both parents
Other _______
_________________________________
Which parent/guardian
is responsible for the
child’s medical bills?
Responsible Party Name:
If not listed above, SS#:
/
Is the student covered by Medicaid:
YES
NO
Is the student covered by health
insurance:
YES
NO
NO
Is it okay to email in non-emergency situations?
If parent/guardian is not
Name:
available, please contact:
Phone:
/
Does the student have a secondary
insurance?
YES
If not listed above, policy holder’s:
Name:
Preferred Drug Store:
Name:
/
NO
SEQ #:
___ ___ ___ ___ ___ ___ ___ ___
Effective Date:
Spend Down:
If yes, insurance name:
Insurance phone number:
Group/Code:
DOB:
NO
If not listed
above,
address:
If yes, Medicaid #
Policy ID#:
If not listed above, policy holder’s:
YES
/
SS#:
Policy Holder’s Name:
/
3KRne:
/
If yes, insurance name & policy #:
DOB:
/
/
SS#:
/
/
Location:
Demographic Data
Is child homeless?
Number in household:
YES
NO
Household monthly income:
Preferred Language:
$
Does patient have WIC?
YES
NO
Is Patient a Veteran?
YES
NO
2011-2012
Medical History – North Country Children’s Clinic, School-Based Health Program
Student’s Name:
Birthdate:
/
/
Student’s Mother’s Maiden Name:
Does the student have allergies?
YES
NO
If yes, allergies include:
Student’s
Medications
(names &
dosages):
Hospitalizations
(dates, hospital
name, reasons):
Ear infection ______________________________
Tonsillitis _________________________________
Chicken Pox _______________________________
Urinary Tract Infection ______________________
Past Medical History
(please provide dates of
illnesses):
Chronic Health Problems
(please give child’s age when
problem began):
Pneumonia _________________________________
Other ______________________________________
___________________________________________
___________________________________________
Asthma __________________________________
Diabetes _________________________________
Cancer ___________________________________
Blood Disorder _____________________________
Does your child have emotional/behavioral
concerns?
YES
NO
Does your child have any developmental delays or
problems?
YES
NO
Does your child have any dental concerns?
YES
NO
YES
NO
Sickle Cell Status __________________________________
Seizure Disorder __________________________________
ADHD or Mental Health Disorder _____________________
Other ___________________________________________
__________________________________________________
If you would like your child to be seen by a counselor at the school-based health
If
you would
like your child
to be seenor
by315-583-5200
a mental health
counselor, please call.
center
call 315-465-3373
(Mannsville)
(Wilson).
If yes, please explain:
If you would like your child to be seen by a dentist at the SBHC please call
.
Does your child see a healthcare specialist?
If yes, name of doctor:
Purpose of visit:
Family History
(Circle any of the following if mom, dad, sisters, brothers, aunts, uncles, or grandparents have had. Please include both sides of the family if applicable.)
Allergies
Migraines
Are there any
smokers in the
house?
Asthma
TB
YES
High blood pressure
Mental health disorder
NO
Stroke
Cancer
High cholesterol
Diabetes
Stomach/GI problems
Hepatitis
Obesity
Seizure disorder
Kidney disease
HIV Positive
History unknown
Siblings (include
names & ages):
Has your child or a close household contact ever: (Please check all that apply)
Had a positive TB screen?
Been infected with tuberculosis of a lung or has taken care of a TB
patient?
Lived in or visited Latin America, SE Asia, Africa, the Caribbean, or
Eastern Europe?
Been a migrant worker?
Taken IV street drugs?
Taken medicine called corticosteroids?
Had concerns about lead poisoning/problems?
Been in prison or a homeless shelter?
I give my consent for my child, _________________________________, to receive services provided by the staff of the North Country Children’s
Clinic’s (NCCC) school-based health center program. In addition, I give my consent for the NCCC staff to have access to my child’s school health
records and copies of my child’s most recent annual physical exam. I give my permission for the release of my child’s reports to his/her health care
provider and the appropriate information from the physical exam to the school nurse. I authorize insurance and/or Medicaid payments for services
rendered for my dependent directly to NCCC and the release of medical information necessary to process claims to my insurance carrier. Services
may include, but are not limited to, the following:
Comprehensive physical examinations ●Treatment of illness and injury ● Monitoring of chronic illness
I understand that every effort will be made to contact me prior to my child’s treatment. The staff at NCCC believes that parental involvement is
essential in keeping children healthy and will encourage each student to involve his or her parents in health care decisions. We encourage parents to
visit or call the school-based health center any time.
Parent/Guardian Signature: _________________________________________________
Date: ______________________
FOR OFFICE USE ONLY:
Reviewed by: _________________________________ Date: _________________