Notice

I understand that Cincinnati Children’s Hospital Medical Center operates the school-based health center in my/my child’s school. I allow Cincinnati Children’s to give care and treatment to me/my child at the school-based health center. I am authorized by law to give consent for my child. This consent is in place until it is removed by me in writing. I have received a copy of Cincinnati Children’s Notice of Privacy Practices. Cincinnati Children’s may use or share health or personal information about me/my child as stated in the Notice. This consent allows Cincinnati Children’s to access and review me/my child’s medical record information from previous providers at the Center, including Neighborhood Health Care, Inc. Please apply any insurance benefits to Cincinnati Children’s for services performed.

What type of insurance do you have for your child? Check all that apply