Dear Parent/Guardian:
Through mutual cooperation between the health department and the school district, a registered nurse has been
assigned to your child’s school for this school year. The nurse will be available to provide a variety of services that
include sick visits, immunizations, physical exams, medication administration, first aid, etc. The nurse will be
available daily at the school health unit.
Enclosed in this packet are consents and forms necessary for your child to be seen by the nurse. Please complete all
forms and sign at the Parent/Guardian signature line. The school nurse will NOT see any student without the
consent form being signed.
For students with needs that are not addressed in the enclosed packet, i.e. daily medication/procedures such as
insulin, Ritalin, Strattera, inhalers, catherizations, etc., the parent/guardian will need to speak to the nurse on an
individual basis. You are welcome to call or visit with the nurse at your child’s school.
You will not be expected to pay anything to the school health unit for services. There will be no charge to
you.
If you have questions or would like additional information regarding school health services, please contact the
school health unit.
We are excited about this valuable resource for our children and hope to make this the best school year ever.
Sincerely,
Jan Chamness
Public Health Director
 117 Civic Center  Mt. Sterling, KY 40353  Phone: 859-498-3808  Fax: 859-498-9082
SCHOOL HEALTH UNIT CONSENT FOR SERVICES 2011-2012
Student Name: _________________________ Grade: ______ Home Room: ______________________
The School Health Unit will offer preventive and acute health care to all students, regardless of income. This includes, but is not limited
to, assessments, medication for minor illnesses (headache, vomiting, etc.) and emergency first aid. Basic laboratory tests will be provided
at the school health clinic when requested by a parent or if a child comes to the clinic with symptoms indicating the need for a lab test. A
Registered Dietician will also be available for chronic disease monitoring/education services such as diabetes counseling..
The School Nurse cannot provide service to your child without this signed consent (except for emergency first aid).
The consent can be withdrawn at any time by the parent or guardian. This consent does not cover immunizations or physicals. You must
contact the School Nurse, or she will contact you for a separate Consent for those services.
I understand that the school nurse ensures free health screenings are completed including height, weight, vision, hearing and scoliosis as
required by law, and that I will be notified of any abnormal findings. I hereby agree to release and hold the staff free and harmless for any
claims, demands, or suits for damages from any injury or complication resulting from treatment approved by me, unless such is the result
of negligence or misconduct on behalf of the school, health department or its employees. This consent is given voluntarily and with full
knowledge of its significance.
I understand that all medications sent from home must be accompanied by proper parent/guardian consent and taken to the school nurse
immediately upon arrival to school for proper storage and administration. Students are not to share any medications with another student.
I understand that non-prescription medications can only be given for three days without a physician’s order.
I understand that in order to ensure my child’s safety, school health services may share educationally relevant health information with
other school personnel having direct involvement with my child.
I authorize designated school personnel to make the determination in the event of an emergency to take my child to the named health care
provider on this form and/or St. Joseph Mt. Sterling for emergency treatment. I further understand that all charges incurred will be my
responsibility.
Please review this form carefully and complete all information that is requested. Return the form to your child’s teacher
The following medications will be available to be administered by the School Nurse after she has evaluated your child’s complaint.
Please review the following list of medications and place a  by the ones you will allow your child to have:
Acetaminophen (generic name for Tylenol) _____
Aloe Vera Gel
_____
Anti-diarrhea Tablets (generic for Imodium) _____
Anti-nausea Liquid
_____
Blistex
_____
Calamine Lotion
_____
Cough Drops
_____
Diphenhydramine (generic name for Benadryl)
______
Hydrocortisone 1% Cream
Peppermint Candy
Bee Sting Wipes
_____
_____
_____
Ibuprofen (generic for Advil)
Sore Throat Spray
Sterile Eye Drops
Triple Antibiotic Ointment
Tussin (generic Robitussin)
Hydrogen Peroxide
Orajel (Multi-Action)
Antacids (Liquid and Chewable)
Glucose Gel/Tablets
Saltine Crackers
Pertroleum Jelly
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
______ Yes, I give my consent for the child listed above to receive the checked medications above at the School Health Clinic.
______ No, I do not wish my child listed above to receive services at the School Health Clinic.
List All Food/Medication/Dye Allergies:_____________________________________________________________
Assignment of Benefits:
I request that payment of authorized medical insurance benefits be made to Montgomery County Health Department on my behalf for services rendered to
my child. I also authorized the health department to release medical information about me to Medicaid, and K-CHIP, to determine payment for services.
I have read this statement and understand that my signature indicates that I do consent and assign benefits as stated above.
By signing this consent I release Montgomery County Health Department and Montgomery County Schools from any liability related to the
administration of medications or treatment as long as Reasonable and Customary care is provided.
_____________________________________
Parent/Guardian Signature
_________________________________
Relationship to child
___________________________
Date (expires in one year )
Revised 5-2011
Effective Date: 04/14/2003
Montgomery County Health Department
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
This Document Describes How Medical Information About You May Be Used And Disclosed And How You Can Get Access To This Information.
Please Read This Notice Carefully.
This Notice of Privacy Practices applies to Montgomery County Health Department. We are committed to safeguarding your personal (protected) health information and to provide you
with notice of our legal duties and privacy practices. We are required to abide by the terms of this notice so long as it remains in effect. We reserve the right to change the terms of this
notice as necessary if the law changes and to make any new notice effective for all protected health information maintained by us.
OUR PRIVACY PROMISE TO YOU
Your health information is personal. Montgomery County Health Department is legally required to protect the privacy of your data. It does so in all aspects of its business.
Montgomery County Health Department has policies about protecting the privacy of your data. These policies comply with State and Federal laws. Montgomery County Health
Department uses and gives out your health information only for: 1) business operations related to providing your health care; 2) when required by law; 3) in responding to health or
natural emergencies; or 4) when necessary to protect the public health and safety.
OUR RESPONSIBILITIES
The Montgomery County Health Department is required to:

Maintain the privacy of your health information. We will not use or disclose your health information without your authorization, except as described in this notice.

Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you

Abide by the terms of the notice currently in effect.

Notify you if we are unable to agree to a requested restriction/amendment

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

Notify you if this notice is revised. We reserve the right to change this Notice of Privacy Practices. We reserve the right to make the new notice’s provisions effective for all
medical information that we maintain, including that created or received by us prior to the effective date of the new notice.

Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. This record contains information about you, including demographic
information that may identify you and that relates to your past, present or future physical or mental health or condition and identifies you, or there is a reasonable basis to believe the
information may identify you. For example, this information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment

Means of communication among the many health professionals who are involved in your care

Means by which you or a third-party payer can check that services billed were actually provided.

Your health record contains protected health information (PHI). State and Federal law protects this information. Understanding that we expect to use and share your health
information helps you to: 1) make sure it is correct;
2) better understand who what, when, where and why others may access your health information; and 3) make more informed decisions when authorizing sharing with others.
Your Health information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. Under the Federal Privacy Rules, 45
CFR Part 164, you have the right to:

Request a restriction on certain uses and sharing of your information (though we are not required to agree to any such request). This means you may ask us not to use or share
any part of your protected health information for purposes of treatment, payment or healthcare operation. You may also ask that this information not be disclosed to family
members or friends who may be involved in your care.

Request that we send you confidential communications by alternative means or at alternative locations. Rule 522

Obtain a paper copy of the notice of information practices upon request.

Inspect and obtain a copy of your health record. Rule 524

Request that your health record containing protected health information (PHI) be changed. Rule 526

Obtain a listing of certain health information we were authorized to share for purposes other than treatment, payment or health care operations after April 14, 2003. Rule 528

Take back your authorization to use or share health information except to the extent that action has already been taken.
How We May Use and Disclose Your Personal (Protected) Health Information
Your personal health information is protected by law. We restrict the use and disclosure of personal health information to employees, business associates, and other individuals or
entities as necessary to carry out treatment, health care operation, and the other purposes as permitted by law and described in this notice. We may use and disclose your protected
health information to you in the manner and for the purpose(s) described in this notice. We will not use or disclose your protected health information without your written
authorization for any purposes except those specifically listed in this notice as not requiring written authorization.
You may revoke your written authorization at any time by notifying us in writing to: Privacy Officer, Montgomery County Health Department, 117 Civic Center, Mt. Sterling,
Kentucky 40453. Your revocation will not affect any use or disclosure made by us in reliance on your prior authorization while it was in effect.
Use or Disclosure for Health Care/Treatment.
We may use medical information about you to provide, coordinate or manage your health care and related services by both us and other health care providers. We may disclose
medical information about you to doctors, nurses, hospitals and other health facilities that become involved in your care. We may consult with other health care providers
concerning you and as part of the consultation share your medical information with them. Similarly, we may refer you to another health care provider and as part of the referral
share medical information about you with that provider. For example, we may conclude you need to receive services from a physician with a particular specialty. When we refer
you to that physician, we also will contact that physician’s office and provide medical information about you to them so they have information they need to provide services for you.
Use and Disclosures for Payment
We may use and disclose medical information about you so we can be paid for the services we provide to you. This can include billing you, your insurance company, or a third
party payor. For example, we may need to give your insurance company information about the health care services we provide to you so your insurance company will pay us for
those services or reimburse you for amounts you have paid. We may also need to provide your insurance company or a government program, such as Medicare or Medicaid, with
information about your medical condition and the health care you need to receive to determine if you are covered by that insurance or program.
Use and Disclosure for Regular Health Operations
We may use and disclose medical information about you for our own health care operations. These are necessary for us to operate Montgomery County Health Department and to
maintain quality health care for our patients. For example, we may use medical information about you to review the services we provide and the performance of our employees in
caring for you. We may disclose medical information about you to train our staff and students working in Montgomery County Health Department. We also may use the
information to study ways to more efficiently manage our organization.
When We May Use or Disclose Protected Health Information
Without Your Written Consent or Authorization
We may use and disclose personal (protected) medical information about you without your written authorization for the following reasons.
To Contact You.
We may contact you by either by telephone or by mail at your home, your office, or at any alternate address or telephone number you have provided us to use. These contacts may
be to remind you of an appointment, or relay other information regarding any health care services being provided by our agency. Telephone messages for you may be left on an
answering machine, by voice mail, or we may utilize an automated service to remind you of any appointments. If you want to request that we communicate to you in a certain way
or at a certain location, you may call or write to: HIPAA Privacy Officer, Montgomery County Health Department, 117 Civic Center, Mt. Sterling, Kentucky 40353, (859) 498-
3808.
To Individuals Involved in Your Care
We may disclose your personal (protected) health information to a family member, friend, or other person involved in your health care. Under normal situations, we would obtain
your written authorization to do so. However, if you are unable to do so because of a medical emergency, accident, incapacity or similar situation and we determine that disclosure
would be in your best interest, we may disclose your personal health information without your written authorization. In these situations, we may disclose personal health
information only to the extent necessary for your health care treatment or payment.
To Obtain or Share Childhood Immunizations Records
A policy of the Kentucky Department for Public Health permits the sharing of childhood immunization information with other local health departments within and outside the state
as well as other facilities or institutions which require evidence of immunizations pursuant to state law, and other providers outside of local health departments who are providing
health care to a patient simultaneously or subsequently.
For Public Health Risks:
We may disclose personal (protected) health information about you for public health activities. These activities general include the following: 1) to prevent or control disease, injury
or disability; 2) to report births and deaths; 3) to report child abuse or neglect; 4) to report reactions to medications or problems with products; 5) to notify people of recalls of
products they may be using; 6) to notify person or organization required to receive information on FDA-regulated products; 7) to notify a person who may have been exposed to a
disease or may be at risk for contracting or spreading a disease or condition; 8) to notify the appropriate government authority if we believe a patient has been the victim of abuse,
neglect or domestic violence (we will only make this disclosure if you agree or when required or authorized by law.
For Health Oversight Activities
We may disclose personal (protected) health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil
rights laws.
To Coroners and Medical Examiners/Funeral Directors:
We may disclose medical information about you to a coroner or medical examiner for purposes such as identifying a deceased person and determining cause of death. We may
disclose medical information about you to funeral directors as necessary for them to carry out their duties.
To Avert Serious Threat to Health or Safety:
We may use or disclose personal (protected) health information about you if we believe the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the
health or safety of a person or the public. We also may release information about you if we believe the disclosure is necessary for law enforcement authorities to identify or
apprehend an individual who admitted participation in a violent crime or who is an escapee from a correctional institution or from lawful custody.
For Judicial and Administrative Proceedings
If you are involved in a lawsuit or a dispute, we may disclose personal (protected) health information about you in response to a court or administrative order. We may also disclose
health information about you in response to a subpoena, discovery request or other lawful process by someone else involved in a dispute, but only if efforts have been made to tell
you about the request or to obtain an order protecting the information requested.
For National Security and Intelligence:
In the event of a state or national emergency, we may disclose medical information about you to authorized state or federal officials to conduct intelligence, counter-intelligence, and
other national security activities authorized by law. An example of this would be if you were or exposed infected with a biological or chemical agent as a result of a terrorist act and
state and federal officials were conducting an investigation.
For Protective Services for the President:
We may disclose personal (protected) medical information about you to authorized federal officials so they can provide protection to the President of the United States, certain other
federal officials, or foreign heads of state.
For Security Clearances:
We may use personal (protected) medical information about you to make medical suitability determinations and may disclose the results to officials in the United States Department
of State for purposes of a required security clearance or service abroad.
On Inmates; On persons in Custody:
We may disclose personal (protected) medical information about you to a correctional institution or law enforcement official having custody of you. The disclosure would be made
without your written authorization only if the disclosure is necessary: (a) to provide health care to you; (b) for the health and safety of others; or, (c) the safety, security and good
order of the correctional institution.
For Workers Compensation:
We may disclose personal (protected) medical information about you to the extent necessary to comply with workers’ compensation and similar laws that provide benefits for workrelated injuries or illness without regard to fault.
To Business Associates:
Some of our services are performed through contractual agreements or business relationships with other providers known as business associates. At times, it may be necessary for us
to provide
certain portions of your personal (protected) health information to one or more of these persons or businesses that assist us with our health care operations. In all cases, we require
these business associates to appropriately safeguard the privacy of your personal (protected) health information. Any subcontract entered by the business associate with whom we
contract shall mandate that the subcontractor is required to abide by the same statutes and regulations regarding confidentiality of personal medical records as is the business
associate.
Other Reasons:
Privacy laws also allow us to release personal (protected) health information for research purposes (under certain circumstances) as well as health information for cadaveric organ,
eye, or tissue donation purposes. Due to the scope of our practice, disclosure for these purposes would be extremely rare, if at all.
COMPLAINTS
If you believe your privacy rights have been violated, and wish to make a complaint you may file a complaint by calling or writing any of the addresses listed below:
The Secretary of Health and Human Services at:
The HIPAA Privacy Officer at:
Secretary of Health and Human Services,
United States Office of Civil Rights by
Montgomery County Health Department
Room 615F
calling 866-OCR-PRIV (866-627-7748) or
117 Civic Center
200 Independence Ave. SW
866-788-4989 TTY.
Mt. Sterling, Kentucky 40353
Washington, D.C. 20201.
859-498-3808
For additional information, call 877-696-6775
POLICY OF NON-RETALIATION
Montgomery County Health Department cannot take away your health care benefits or retaliate in ANY way if you choose to file a privacy complaint or exercise any of your
privacy rights.
WHERE DO I SEND QUESTIONS OR REQUESTS?
To submit questions about your privacy rights or to submit a written request to Montgomery County Health Department regarding your privacy right, you may write or call our
HIPAA Privacy Officer at: Montgomery County Health Department, 117 Civic Center, Mt. Sterling, Kentucky 40353, (859) 498-3808
MONTGOMERY COUNTY HEALTH DEPARTMENT
ACKNOWLEDGMENT FOR RECEIPT OF NOTICE OF PRIVACY PRACTICES
Notice to Patient:
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your
health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you
wish.
I acknowledge that I have received a copy of Montgomery County Health Department’s Notice of Privacy Practices.
Please print your name here.
________________________________________________________________________________________
Please sign your name here.
_____/_____/_______
Today’s Date
________________________________________________________________________________________
Please print name of witness.
________________________________________________________________________________________
Witness: Please sign your name here.
_____/_____/_______
Today’s Date
The School Health Unit offers health care to all students in Montgomery County Schools regardless of income, race, religion, sex,
national origin, age, disability, political affiliation or belief.
FOR OFFICE USE ONLY
We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient
but it could not be obtained because:
 The patient refused to sign.
Due to an emergency situation it was not possible to obtain an acknowledgement.
We were not able to communicate with the patient.
Other (Please provide specific details.):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________
_________________________________________
Employee Signature
_____/_____/_______
Today’s Date
Student Information 2011-2012 School
Year
Students Name: _________________________________ Grade_____ Birth date: _____________
SS#_____________________ Address_____________________________________________
Legal Guardian(s):________________________Phone # (____) __________________________
Mother’s Name__________________________ Home # (____) ___________________________
Cell # (___) ____________ Daytime # (_____) _____________ Email: ______________________
Father’s Name__________________________ Home # (____) ___________________________
Cell # (
)
Daytime # (
)
Email:
Emergency Contacts (must be different than listed above)
1. _____________________________
Phone #__________________________
2. _____________________________
Phone #__________________________
Child’s Doctor____________________________ Phone #_____________________
Does your child have the following coverage? Health Insurance Yes No K-CHIP
Yes
Medicaid
Yes
No
Does your child have Dental Coverage?
Yes
No
No
Please mark the following conditions that have been diagnosed by a healthcare provider:
ADD/ADHD
Past
Present
Anaphylactic Episode
Past
Present Type:__________________________
Asthma
Past
Present
Blood Disorder
Past
Present
Cancer
Past
Present
Cardiac/Heart Disorder
Past
Present Type:___________________________
Cystic Fibrosis
Past
Present
Diabetes
Past
Present Type:___________________________
Tuberculosis
Past
Present
Immune Disorder
Past
Present Type:___________________________
Metabolic Disorder
Past
Present Type:___________________________
Migraines
Past
Present
Mood Disorder
Past
Present Type:___________________________
Seizures
Past
Present Type:_________________________
Stomach/Bowel
Past
Present
Other Medical Conditions:_____________________________________________________________________
Current Medications:__________________________________________________________________________
If you marked a Present condition above, an individualized health plan (IHP) needs to be completed by you
and your child’s healthcare provider and returned to the nurse. Please contact the school nurse for the
appropriate form(s). This information helps the nurse manage and monitor your child’s condition. A student
may not carry a medication (insulin, asthma inhalers, epi-pens etc) with them UNLESS written permission
from their health care provider is provided.
Not completing an IHP may prevent your child from attending school field trips and events.
2011-2012 School
Year