Consent

Purpose
Sharing your child’s electronic health information in the Virtual Health Village will allow their health care provider and school health office to review all of his or her medical history and treatments. This will help your child’s health care provider and school nurse to make better informed decisions about your child’s medical care.

By signing this consent, you agree to allow your child’s health information to be used by health care providers at participating hospitals, pediatric clinics and your child’s school. The information will be used to provide your child with medical treatment and educational/school-based needs as explained further in this Consent form.

Sharing your child’s electronic health information in the Virtual Health Village is your choice. If you decide not to share your child’s electronic health information, that will not prevent you from seeking and/or obtaining health care from participating providers. Your decision to participate or not participate will not affect your child’s insurance eligibility.

What is the Virtual Health Village?
The Virtual Health Village is a name that the Children's Health Care Alliance is calling its electronic health information exchange, or “HIE”. This HIE will permit a collaboration of local health care providers and your child’s school district to share information about your child’s medical condition that will help the hospitals, pediatric clinics and your child’s school health nurses access information necessary to provide services to your child.

Types of Information Included in this Consent
If you give consent, any participating health care provider and your child’s school may view and share ALL of your child’s health information available in their records. This includes information created before and after the date of this consent form. Your child’s health records may include a history of illnesses or injuries your child has had (like diabetes or a broken bone), test results (like x-rays or blood tests), and medicines he or she has taken.

Some state and federal laws provide additional rules for sensitive health conditions. The Virtual Health Village will follow all applicable state and federal laws while participating in the Virtual Health Village, including those laws regarding specific sensitive health conditions.

Where Health Information about your child comes from
Information about your child’s health comes from places that have provided your child with health care. These places may include hospitals, physicians’ offices, pharmacies, clinical laboratories, and other organizations that exchange health information electronically. They also come from your child’s school records, including his/her student health records, nursing records, special education and Section 504 records.

Who may access information about your child, if you give consent
Only people providing your child with health care services and your child’s school are allowed to access your child’s electronic health information. At your child’s school, the school nurses will primarily be the individuals accessing the records, but they may share the information with other individuals at the school who have a legitimate educational interest in the information, including teachers, guidance counselors and administrators. By giving your consent to participate in the Virtual Health Village, you are agreeing that the records and information contained within the Virtual Health Village may become part of your child’s educational records at the school.

Withdrawing your consent
You can withdraw your consent to participate in the Virtual Health Village at any time. If you withdraw your consent, your child’s electronic health information will continue to be stored with your child’s health care provider and your child’s school. Your decision to stop your child’s participation in the Virtual Health Village will not affect your child’s access to care or adversely impact your child’s academic record.

Providers who view or share your child’s electronic health information through the Virtual Health Village while your consent is in effect may copy or include your child’s information in their own electronic health records system. Even if you later decide to withdraw your consent, they are not required to remove the information from their records, and they may continue to use and/or disseminate that information as permitted by law.

Effective period
Your consent will remain in effect until (1) you withdraw your consent; (2) your child attains age eighteen (18); or (3) your child is no longer enrolled in their current school district.

Upon your child attaining age eighteen (18), a new consent form must be signed by your child for continued participation.

In the event that your child enrolls in another school district participating in the Virtual Health Village, a new consent form must be signed for continued participation.

Questions
If you have any additional questions about consenting to your child’s participation in the Virtual Health Village, please contact your School Nurse or Health Care Provider.

I have been given the opportunity to ask questions and all of my questions have been answered. I understand the benefits and risks of my child’s participation in the Virtual Health Village and consent to his/her participation.

You will receive a signed copy of this consent form to keep and refer to.

Please complete one consent form per child.

Child's Name (required)

Child's Date of Birth (required)

Child's Grade Level (required)

School District (required)
 Allentown School District Bethlehem Area School District

Allentown School District Schools

Bethlehem Area School District Schools

Parent or Guardian Name (required)

Relationship to Child (required)
 Parent Guardian

Email

Entering your name in this field will act as your digital signature. (required)

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