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 understand that CCHMC may take photographs, films, or audiovisual recordings (“images”) of the patient to use for diagnosis, treatment, identification of the patient and internal purposes such as staff training, medical education, performance improvement, and other organizational activities. CCHMC may provide certain services utilizing telehealth technology, including transmission of images, video and audio that are encrypted for privacy. The remote provider will determine whether the condition being diagnosed or treated is appropriate for telehealth, and I understand that there is no guarantee of diagnosis, treatment, or prescription for myself/my child. I understand that I/my child may have to travel to see a health provider in-person for certain diagnosis and treatment or in the event of a technical failure. 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.
