My child, _______________________________________________, does not have my permission (please check one) to be seen by the health care provider(s) from Nationwide Children’s Hospital at the School Based Mobile Care Center. I understand I will receive either a written or phone follow-up report when my child is seen. I also give permission for the health care provider to review the South Western City School Health Records for any information related to my child’s health. I understand that if I can’t be with my child when they receive immunizations that I must sign a vaccine form before my child receives any immunizations on the Mobile Van. I understand that a written report will be sent to my child’s doctor when follow-up care is necessary. If my child has a fever, or is in pain, you may give him/her Tylenol or Motrin If my child has a scrape on his/her skin, you may apply an antibiotic ointment (Neosporin) and bandage if necessary. I consent to let the Nationwide Children’s share/release/exchange information such as medical, clinical research, physical, mental, drug, and alcohol, HIV or AIDS (including information that state and federal law and accreditation agencies require); concerning my child/ward that may be requested to/with my doctors, the school nurse and or to any insurance company or organization that helps pay my bill. The Hospital may also give information of any to any welfare organization to which I have applied or may apply to for aid. This permission remains valid unless revoked in writing by me. I (or guarantor) if appropriate, will pay all bills for the care provided including bills that insurance benefits do not pay. I assign to Nationwide Children’s, my physician and other healthcare professional involved in my care, all my rights and claims for reimbursement under any private health insurance policy. Medicare, Medicaid, or any other programs that I identify for which benefits may be available to pay the Hospital for medical services provided. I agree to cooperate and provide information as needed to establish my eligibility for such benefits. Nationwide Children’s may keep, preserve, and use, or properly dispose of any tissue, or sample that are taken during procedures. These specimens may be used for diagnostic, teaching or training purposes. I authorize Nationwide Children’s to take photos, video, or audio recording of the patient for diagnostic, teaching, care conferencing, research and quality improvement purposes. I hereby acknowledge that I declined a copy of the Notice of Privacy Practices of Integrated Child Healthcare Arrangement (ICHA)which sets forth the ways in which my protected health information may be used or disclosed by Nationwide Children’s and outlines my rights with respect to such
**I have received a copy of the Patient’s Bill of Rights and have had my questions answered.

Parent / Guardian Signature
_____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Witness Signature (examples: neighbor, adult relative)
Name & Address of child’s doctor or clinic (if they have one)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Mobile Use Only
Permission given by phone for ________________________________to be seen and treated by Nationwide Children’s Hospital Mobile Care Center from
______________________________________________________, ______________________________________________. ________-_____-________ (Parent/Guardian’s ___________________________________________ _______________ _____________________________________ ____________________ Nationwide Children’s Hospital Employee Nationwide Children’s Hospital Mobile to Mobile Close to Home Centers
Date: ______________________
Child’s Name: ____________________________ DOB: ____________ Sex: ______ Child’s Social Security #: ____-____-____
Child’s School / Grade: ____________________________________ Home Phone: _______________________________

Emergency Contact Name / Number: ____________________________________________________________________
Are your children eligible for the Free Lunch Program in the School

Mother’s Name: ______________________________ DOB: _________________ Social Security #: _____-____-______
Home Phone: ___________________ Daytime/Work Phone: ___________________ Cell Phone: _______________________

Employer Name : ________________________________________________

Father’s Name: ________________________________ DOB: _________________ Social Security#: _____-____-_______
Home Phone: ____________________ Daytime Phone: ______________________ Cell Phone: ________________________

Employer: ______________________________

Pharmacy Name/Location/Phone #:
Does your child have any allergies to any medicine? Name of Medicine (s): __________________________________________________________________ Is your child taking any medications now? No Name of Medicine (s): _____________________________________________________________________ Does your child have any Health problems? No If yes, please describe: __________________________________________________________________________
Medical Mutual Group & ID #: _________________________________________
Do you need insurance? Got you covered-
Sign up for free health insurance! Caresource and Molina are companies that provide managed care Medicaid insurance for
qualified children. Call 2-1-1 to make an appointment. You’ll meet with a counselor from Nationwide Children's Hospital to
determine your child’s eligibility and to gather information to enroll or recertify your child for Medicaid.

NCH MOBILE: 614-306-1005
PATIENT ACCTS: 614-722-2055

Source: http://www.wcs.k12.oh.us/ourpages/auto/2010/5/20/46779544/Ronald%20McDonald%20Permission%20Form.pdf

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