Revised 8/02/17 KEEP FOR YOUR RECORDS Revised 1/23/2017

ELLIOT P. SCHLANG, DDS - GENERAL DENTIST, DENTAL DIRECTOR NYC Department of Education Oral Health Clinic Program School Parental Consent Form Angelina Adames, DDS, Jungmin Cho, DMD, Jennifer Corredor, DDS, Sylvia Cuellar, DDS, Joseph D’Ambrosio, DMD, Jason Davis, DDS, Christopher Dillon, DDS, Andrew Fradkin, DDS, Margaret Garland, DDS, Renee Gaska, DMD, Page 1 of 2 Jeffrey Gershon, DMD, Daria Grillo, DDS, Barry Hecht, DMD, Deborah Kahn, DMD, Sahar Kamkar, DMD, Aditi Kapoor, DMD, Uzma Khan, DDS, Jeffrey Krantz, DDS, Stephen Marshall, DDS, Deena Pegler, DMD, Alan Poritzky, DDS, SMILE NEW YORK OUTREACH, LLC* Melissa Rodgers, DMD, Deniz Salierno, DDS, Elliot Schlang, DDS, Karimeh Shehadeh, DDS, Jeffrey Tenenbaum, DDS, Nancy Yu, DDS 37-30 Review Ave., Suite 102, Long Island City, NY 11101 Phone: 855-469-7473 Fax: 888-330-4331 NOTICENOTICE OF OF PRIVACY PRIVACY PRACTICES PRACTICES STUDENT INFORMATION PARENT/GUARDIAN INFORMATION THISTHIS NOTICE NOTICE DESCRIBES DESCRIBES HOW MEDICAL HOW MEDICAL INFORMATION INFORMATION ABOUT YOU ABOUT MAY YOU BE USED MAY ANDBE USED DISCLOSED AND DISCLOSED AND HOW YOU AND CAN HOW GET YOU ACCESS CAN GETTO THIS ACCESS INFORMATION. TO THIS PLEASE REVIEW IT CAREFULLY. KEEP FOR YOUR RECORDS INFORMATION. PLEASE REVIEW IT CAREFULLY. KEEP FOR YOUR RECORDS Student’s Last Name: ______OUR LEGAL DUTY Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as Mother The privacyOUR ofLEGAL your medical DUTY information is important to us. We are required by applicable federal and state law to voicemail messages, postcards, letters, emails or text messages). Student’s First Name: ______Last Name: ______First Name: ______maintainThe the privacy privacy ofof your your health medical information. information We are also is requiredimportant to give to youus. this We Notice are about required our privacy by applicable practices, federal and state law to maintain the privacy of your health information. We are also required our legalto give duties, you and this your Notice rights concern¬ing about our your privacy health practices, information. ourWe mustlegal follow duties, the privacy and your practices rights that concern¬ingare Health your Oversight health Activities: information. We may Wedisclose must health follow information the privacyto a health practicesoversight agency that for are activities described authorized in by this law. Date of Birth: ______/______/______Father describedNotice in this while Notice it iswhile in effect.it is in effect. We Wewill will notify notify you you ifif your your unsecured unsecured medical medical information information is breached. is breached.These oversight activities include, for example, audits, investigations, inspections and licensure surveys. These activities are necessary for the government to monitor the health care system, the outbreak of disease, government programs, compliance with civil rights laws Month Day Year Last Name: ______First Name: ______We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such and to improve patient outcomes. changesWe arereserve permitted the by right applicable to change law. We ourreserve privacy the right practices to make the and changes the terms in our privacy of this practices Notice at any time, provided such changes are permitted by applicable law. We reserve the right School______Grade______and theto makenew terms the of changesour Notice effectivein our forprivacy all health practices information and that wethe maintain, new terms including of ourhealth Notice information effective Lawsuits for all health and Disputes: information We may disclose that we health maintain, information including about you in responsehealth informationto a court or administrative we created order. Weor may we createdreceived or received before before we madewe made the the changes. changes. Before Before we makewe make a significant a significant change in changeour privacy in our privacyalso disclose practices, health information we will about change you in response this Notice to a subpoena, and discoverymake the request new or other Notice lawful available process. upon Legal Guardian, If Applicable practices,request. we will change this Notice and make the new Notice available upon request. Other Uses and Disclosures. As permitted or required by law, we may use or disclose your medical information for research Teacher’s Name:______Last Name: ______First Name: ______You may request a copy of our Notice at any time. For more information about our privacy practices, or for purposes; to organizations that handle and monitor organ donation and transplantation; for workers’ compensation or similar additionalYou Youmay request copiesmay request ofa copythis Notice, of aour copy Noticeplease of atcontact our any Noticetime. us using For at more the any information information time. For listed about more at our the privacyinformation end of practices,this Notice. about or for our privacypurposes; practices, to organizations or forthat handleadditional and monitor copies organ ofdonation this andNotice, transplantation; please for contact workers’ compensation us using orthe similar Relationship of legal guardian to student additionalinformation copies of listedthis Notice, at the please end contact of this us Notice.using the information listed at the end of this Notice. programs to comply with laws related to workers’ compensation or similar programs that provide benefits for work-related injuries or illness; for public health activities such as to prevent or control disease, injury or disability; to report reactions to medications or Student’s Social Security Number: ______   USES AND DISCLOSURES OF HEALTH INFORMATION problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed Grandparent Aunt or Uncle Other: ______WeUSES useUSES AND and DISCLOSURES discloseAND DISCLOSURES health OF information HEALTH OF INFORMATIONabout HEALTH you for treatment, INFORMATION payment, and healthcare operations. problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed (Optional, but helpful) ForWe useexample: and disclose health information about you for treatment, payment, and healthcare operations. to, or is at risk for contracting or spreading a disease; to medical examiners to identify a deceased person or determine cause of For example:We use and disclose health information about you for treatment, payment, and death;healthcare or to funeral operations. directors to carry outFor their example: duties. Sex:  Male  Female Treatment: We may use or disclose your health information to a physician, school nurse, or other healthcare Contact Information for parent or guardian Treatment:Treatment: We may We use ormay disclose use youror disclose health information your health to a physician, information school tonurse, a physician, or other healthcare school nurse,PATIENT or RIGHTSother healthcare provider providing treatment to you. provider providing treatment to you. Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in :  Hispanic  Black  White  American Indian Payment:Payment: We may We use mayand disclose use and your disclose health information your health to obtain information payment for servicesto obtain we paymentprovide to you. for serviceswriting we to obtain provide access to to you. your health information and fax your request to the number at the end of this Notice. Ethnicity Home Tel: ______Work Tel: ______Payment: We may use and disclose your health information to obtain payment for services we provide to you.  Asian/Pacific Islander  Other ______Healthcare Operations: We may use and disclose your health information in connection with our business Disclosure Accounting: You have the right to receive a list of some disclosures we or our business associates have made of your Cell: ______HealthcareHealthcare Operations: Operations: We may use We and maydisclose use your and health disclose information your in connectionhealth information with our business in connection health withinformation. our Ifbusiness you request thisoperations accounting more such than as once reviewing in a 12-month the period, competence we may charge oryou qualifications a reasonable, cost- operationsof healthcare such as reviewing professionals the competence and evaluating or qualifications practitioner of healthcare and professionals provider and performance. evaluating based fee for responding to these additional requests. practitioner and provider performance. based fee for responding to these additional requests. Student Address:______Email: ______Restriction: You have the right to request that we restrict our use or disclosure of your health information. We are not required to YourYour Authorization: Authorization: Uses or disclosures Uses or not disclosures otherwise described not otherwise in this Notice described may be made in this only Noticewith your may Restriction:be made You only have with the right your to request written that authorization. we restrict our use or Indisclosure addition, of your we health must information. obtain We your are not written required to writtenauthorization authorization. UsestoIn addition,sell or disclosuresyour we medicalmust not obtain otherwise information your written described authorization or toin thisuse Notice orto selldisclose may your be medical made your only information information with your foragree marketing to your request goods except or when services disclosure to would you be wh to yourere health we areplan, youpaid (or tosomeone make on theyour behalfcommunication. other than your healt If h ______orwritten to use authorization. or disclose your In addition, information we mustfor marketing obtain your goods written or services authorization to you to where sell your we medicalare paid informationto make the plan) has paid in full for your health care, the disclosure relates to payment or health care operations, and the disclosure is not or to youuse orgive disclose us an your authorization, information for marketing you may goods revoke or services it in writing to you where at any we aretime. paid Your to make revocation the otherwise will not required affect by law. any If we use agree or to disclosuresthe restriction, however, permitted we will abide by byyour that agreementauthorization (except in whilean emergency). it was City State Zip Code Additional Emergency Contact communication.in effect. UnlessIf you give you us an give authorization, us a written you may authorization, revoke it in writing we atcannot any time. use Your or revocationdisclose your healthotherwise information required by law. for If we any agree reason to the restriction, except however, those we described will abide by that in agreementthis Notice. (except in an emergency). will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give Name: ______us a written authorization, we cannot use or disclose your health information for any reason except those Alternative Communication: You have the right to request in writing that we communicate with you about your health information us a Towritten Your authorization, Family and we cannot Friends use orand disclose Persons your health Involved information in Your for any Care: reason We except may those disclose yourby alternative health meansinformation or to alternative to a familylocations member, specified in your friend written or request. other person involved in your care to describedthe extent in this Notice.necessary to help with your healthcare or with payment for your healthcare. Weby may alternative also means disclose or to alternativeyour medical locations information specified in your to written disaster request. relief organizations to help locate IMPORTANT HEALTH QUESTION Relationship to Student: ______To Yourindividuals Family and during Friends a disaster.and Persons We Involved may alsoin Your use Care: or discloseWe may disclose your medicalyour health information information to toa notify,Amendment: or assist You in have the the notification, right to requestRECORDS of that a wefamily amend member, your health ainformation. personal Your representative request must be in or writing a person and must To Your Family and Friends and Persons Involved in Your Care: We may disclose your health information to a Amendment: You have the right to request that we amend your health information. Your request must be in writing and must Does your child have any medical condition that may com- Home Tel: ______Work Tel: ______familyresponsible member, friend for or your other careperson of involved your location, in your care general to the extent condition necessary or death.to help with If youyour healthcaredo not want or us explainto disclose why the yourinformation medical should informationbe amended. We to may family deny membersyour request underor oth certainers circumstances.in these circumstances, with paymentplease fornotify your ourhealthcare. HIPAA We Officer may also at disclose 888-833-8441. your medical information to disaster relief organizations to plicate dental treatment? This may include heart issues, Cell: ______help locate individuals during a disaster. We may also use or disclose your medical information to notify, or assist Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in in the notification, of a family member, a personal representative or a person responsible for your care of your location, written form upon request. breathing problems, seizures, allergies, bleeding problems, generalin theRequired notification, condition ofor by adeath. family Law: Ifmember, you We do maynot a personal want use us representativetoor disclose disclose your or your medicala person health information responsible information to for family your memberscare when of your or we othlocation, areers in required to do so by law. Email: ______thesegeneral circumstances, condition or death. please If notifyyou do our not HIPAA want us Officer to disclose at 888-833-8441. your medical information to family members or others in QUESTIONS AND COMPLAINTS communicable diseases, immune disorders, etc. If Yes, explain. thesePublic circumstances, Safety: please We notify may our need HIPAA toOfficer disclose at 888-833-8441. medical information to law enforcement officials,QUESTIONS such AND asCOMPLAINTS in response to a search warrant or a grand jury subpoena, or to If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned ______Requiredassist by law Law: enforcement We may use or officialsdisclose your in identifying health information or locating when we an are individual, required to do to so report by law. deaths that that we may have have violated resulted your privacy from rights, crimina you may lcomplain conduct, to us andusing theto contactreport information criminal listed conduct at the end on of this our Notice. IF NO, LEAVE BLANK premises. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any way if Public Safety: We may need to disclose medical information to law enforcement officials, such as in you choose to file a complaint with us or the U.S. Department of Health and Human Services. responseAbuse to a or search Neglect: warrant We or a maygrand disclose jury subpoena, your or health to assist information law enforcement to appropriate officials in identifying authorities or if weContact reasonably Officer: HIPAA believe Officer that you are a possible victim of abuse, neglect, or domestic locatingviolence an individual, or the to possible reportKEEP deaths victim that of may other have crimes. resulted We from FOR maycriminal disclose conduct, and your to report health YOUR YOURcriminal information Contact to Officer: the HIPAA extent RECORDSOfficer necessary to avert a serious threat to your health or safety or the DENTAL INSURANCE INFORMATION conducthealth on our or premises. safety of others. Phone: 888-833-8441 Fax: 888-330-4331 Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a Does your child have Medicaid? Does your child have coverage through your employer or any possibleNational victim of abuse, Security: neglect, Weor domestic may discloseviolence or theyour possible medical victim ofinformation other crimes. Weto militarymay disclose authorities your health of Armed email: Forces [email protected] or foreign military personnel under certain circumstances; to authorized federal other type of dental health insurance? informationofficials to forthe lawfulextent necessary intelligence, to avert counterintelligence,a serious threat to your health or otheror safety national or the health security or safety activities, of others. and Effectiveto protect Date: the August president; 1, 2016 and to a correctional institution or law enforcement official having  No  Yes: Medicaid ID # ______lawful custody of an inmate or patient under certain circumstances. Effective Date: August 1, 2016  No  Yes, Health Plan: ______National Security: We may disclose your medical information to military authorities of Armed Forces or foreign military personnel underAppointment certain circumstances; Reminders: to authorized federal We officialsmay use for lawful or disclose intelligence, your counterintelligence, health information or other national to provide security you with appointment reminders (such as voicemail messages, postcards, letters, emails or Does your child have Child Health Plus? Member ID or Social Security Number: ______activities,text and messages). to protect the president; and to a correctional institution FORor law enforcement official having lawful custody of an inmate or patient under certain circumstances.  No  Yes: CHP # ______Health Insurance Phone: ______Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure surveys. These activities are necessary for the government to monitor the health care system, the outbreak of disease, government programs, Which Plan? Name of Insured Adult: ______compliance with civil rights laws and to improve patient outcomes.  Affinity  Fidelis Birth Date of Insured Adult:______Lawsuits and Disputes: We may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in  Healthfirst  Health Plus Amerigroup response to a subpoena, discovery request or other lawful process.  HIP  MetroPlus If your child does not have health insurance, would you like Other KEEPUses and Disclosures. As permitted or required by law, we may use or disclose your medical information for research purposes; to organizations that handle and monitor  WellCare  United Healthcare an In-Person Assistor authorized by the NY State of Health organ donation and transplantation; for workers’ compensation or similar programs to comply with laws related to workers’ compensation or similar programs that provide benefits  MVP  Empire BlueCross BlueShield Marketplace to contact you to enroll into health insurance? for work-related injuries or illness; for public health activities such as to prevent or control disease, injury or disability; to report reactions to medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to, or is at risk for contracting or spreading a disease; to medical examiners to  No  Yes What is the best time to contact you? identify a deceased person or determine cause of death; or to funeral directors to carry out their duties.  Other ______PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health informa- PARENTAL CONSENT FOR SCHOOL-BASED ORAL HEALTH CLINIC SERVICES tion and fax your request to the number at the end of this Notice. Disclosure Accounting: You have the right to receive a list of some disclosures we or our business associates have made of your health information. If you request this accounting I have read and understand the services listed on the next page (School-Based Oral Health Clinic Services) and my signature provides consent more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. for my child to receive services provided by the Smile New York Outreach, LLC School-Based Oral Health Clinic for as long as my child is enrolled at school. I may withdraw my consent at any time by written notice to Smile New York Outreach, LLC. I have read the IMPORTANT HEALTH Restriction: You have the right to request that we restrict our use or disclosure of your health information. We are not required to agree to your request except when disclosure QUESTION above and will report any significant changes in my child’s health to 855-481-8638. We may send you text messages about the school would be to your health plan, you (or someone on your behalf other than your health plan) has paid in full for your health care, the disclosure relates to payment or health care dental program. Message and/or data fees may be charged by your wireless service provider; to discontinue, reply “STOP” to any message received operations, and the disclosure is not otherwise required by law. If we agree to the restriction, however, we will abide by that agreement (except in an emergency). from us. You also agree to receive pre-recorded and/or auto-dialed telephone calls relating to the school dental program at the land-line and/or Alternative Communication: You have the right to request in writing that we communicate with you about your health information by alternative means or to alternative locations mobile telephone numbers provided on this consent form. NOTE: By law, parental consent is not required for students who are 18 years or older or specified in your written request. for students who are parents or legally emancipated. My signature indicates I have received a copy of the Notice of Privacy Practices. Amendment: You have the right to request that we amend your health information. Your request must be in writing and must explain why the information should be amended. We may deny your request under certain circumstances. X ______(or student if 18 years or older or otherwise permitted by law) Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form upon request. Signature of Parent/Guardian Date HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF HEALTH INFORMATION QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, you I have read and understand the release of health information on page 2 of this form. My signature indicates my consent to release oral may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. health information as specified. We will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services. Contact Officer: HIPAA Officer Phone: 888-833-8441 X ______Fax: 888-330-4331 Signature of Parent/Guardian (or student if 18 years or older or otherwise permitted by law) Date email: [email protected] Effective Date: August 1, 2016 PLEASE BE SURE TO REVIEW BOTH SIDES OF THIS CONSENT NY-NYC-ENG-010V1 Revisedd 1/ 8/02/17 3/ NYC Department of Education Oral Health Clinic Program Page 2 of 2 School Parental Consent Form Patient’s Bill of Rights SMILE NEW YORK OUTREACH, LLC* 37-30 Review Ave., Suite 102, Long Island City, NY 11101 As a patient of Smile New York Outreach, you have the right to: Phone: 855-469-7473 Fax: 888-330-4331 Page 2 of 2 SCHOOL-BASED ORAL HEALTH CLINIC SERVICES 1. Understand and use these rights. If for any reason you do not understand or you need help, the Center must provide assistance, including an interpreter. I consent consent for my child child to receivereceive oral health care services provided by the State-licensedState-licensed health professionals of Smile New York Outreach, LLC as part of the school oral health program approved by the New York StateState DepartmentDepartment of Health for as long as my childchild isis enrolledenrolled at 2. Receive services without regard to age, race, color, sexual orientation, religion, marital atschool school.. I understandI may withdraw that myconfidentiality consent at betweenany time theby writtenstudent notice and the to Smileoral health New Yorkclinic Outreach, provider will LLC. be Iensured understand in specific that confidentiality service areas in betweenaccordance the withstudent the law,and theand oral that health pupilsSCHOOL clinicwill be provider encouraged-BASED will be ORALto ensured involve HEALTH theirin specific parents CLINIC service or guardiansSERVICES areas in in accordancecounseling andwith ortheal law,care anddecisions. that pupils status, sex, national origin or source of payment. willSchool be encouraged-Based Oral toHealth involve Clinic theirS ervicesparents mayor guardians include, butin counseling are not limited and oralto p reventativecare decisions. oral healthSchool-Based services ,Oral restorative Health Clinicoral health Services ser- mayIvices consent include,, and for emergency mybut childare not to procedures receivelimited to,oral thatpreventative health range care from oral services comprehensive health provided services, dentalby restorative the exams,State- licensedservices, dental hygienehealth and emergency professionals treatments, procedures. xof-rays,Smilefluoride NewPreventative York treatments, Outreach, oral 3. Be treated with consideration, respect and dignity including privacy in treatment. healthLLCsealants,as services part fillings, of the include, and school extractions but oral arehealth not. limited program to, comprehensiveapproved by the dental New York exams, State dental Department hygiene oftreatments, Health for x-rays,as long sealants as my child and isfluoride enrolled at treatments.school. I understand This may thatalso confidentialityinclude the application between theof Silver student Diamine and the Fluoride oral health on back clinic teeth provider to halt will the be progression ensured in specificof cavities service (The areasuse of in 4. Be informed of the services available at the Center. Silveraccordance Diamine with Fluoride the law, may and discolor that pupils anyNEW will cavities be YORK encouraged to a brownCITY to DEPARTMENTor involve black color). their parents For OF services EDUCATION’Sor guardians other than in counseling comprehensive and or dentalal care exams decisions. and preventativeSchool-Based oral Oral health Health services, Clinic S Smileervices New may York include, Outreach, but are LLC not shall limited notify to pthereventative parent/guardian oral health of the services services, restorative and treatments oral health to be se r- FACT SHEET FOR PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION 5. Be informed of the provisions of off-hour dental emergency coverage. provided,vices, and including emergency but proceduresnot limited tothat fillings, range fromextractions, comprehensive and the usedental of anesthetics exams, dental or otherhygiene medications. treatments, If thex-rays, parent/guardianfluoride treatments, does not HIPAA COMPLIANT PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION consent,sealants, thesefillings, services and extractions shall not. be performed. 6. Be informed of the charges for services, eligibility for third-party reimbursements and, My signature on the reverse side of this form authorizes release of oral health information. This information may be protected from disclo- when applicable, the availability of free or reduced cost care. sure by federal privacy law and state law.NEW YORK CITY DEPARTMENT OF EDUCATION’S FACT SHEET FOR PARENTAL CONSENT FOR RELEASE OF ORAL HEALTH INFORMATION 7. Receive an itemized copy of his/her account statement, upon request. By signing thisHIPAA consent, COMPLIANT I am authorizing PARENTAL oral health informCONSENTation to FOR be given RELEASE to the Board OF ORALof Education HEALTH of the INFORMATION City of New York (a/k/a New York City Department of Education) as well as school nurses and leaders, either because it is required by law or by Chancellor’s regulation, 8. Obtain from his/her health care practitioner, or the health care practitioner’s delegate, Myor because signature it ison necessary the reverse to side protec of tthis the form health authorizes and safety release of the ofstudent. oral health Upon information. my request, This the informationfacility or person may be disclosing protected this from oral discl healtho- sureinformation by federal must privacy provide law me and with state a copy law. of this form. Parents are required by law to provide certain information to the school, like proof of complete and current information concerning his/her diagnosis, treatment and prognosis in immunization. Failure to provide this information may result in the student being excluded from school. terms the patient can be reasonably expected to understand. By signing this consent, I am authorizing oral health information to be given to the Board of Education of the City of New York (a/k/a New YorkMy questions City Department about this of formEducation) have been as well answered. as school I nursesunderstand and leaders that I do, either not have because to allow it is release required of by my law child’s or by oral Chancellor’s health information, regulation, 9. Receive from his/her dentist information necessary to give informed consent prior to the start orand because that I can it ischange necessary my mindto protec at anyt the time health and and revoke safety my ofauthorization the student. by Upon writing my to request, the School the -facilityBased orOral person Health disclosing Clinic. However,this oral health after a informationdisclosure has must been provide made, me it withcannot a copy be revoked of this form. retroactively Parents to are cover required information by law releasedto provide prior certain to the information revocation. to the school, like proof of of any non-emergent procedure or treatment or both. An informed consent shall include, as a immunization. Failure to provide this information may result in the student being excluded from school. minimum, the provision of information concerning the specific procedure or treatment or both, I authorize Smile New York Outreach, LLC School-Based Oral Health Clinic to release specific oral health information of the student named the risks involved, and alternatives for care or treatment, if any. Myon thequestions reverse about page thisto the form Board have of been Education answered. of the ICity understand of New York that I (a do/k /nota New have York to allow City Departmentrelease of my of child’sEducation). oral health information, and that I can change my mind at any time and revoke my authorization by writing to the School-Based Oral Health Clinic. However, after a disclosureI consent tohas the been release made, from it cannot the School be revoked-Based retroactively Oral Health to coverClinic informationto the NYC released Department prior toof theEducation revocation. and from the NYC Depart- 10. Refuse treatment to the extent permitted by law and to be fully informed of the medical ment of Education to the School-Based Oral Health Clinic, of oral health information outlined below in order to meet regulatory consequences of his/her action. Irequ authorizeirements Sm ileand New ensure York thatOutreach, the school LLC School has information-Based Oral needed Health Clinic to protect to release my child’s specific health oral health and safety.information I understand of the student that named this oninformation the reverse will page remain to the confidential Board of Education in accordance of the City with of FederalNew York and (a /Statek/a New law York and City Chancellor’s Department Regulations of Education). on confidentiality: 11. Refuse to participate in experimental research. Information to Protect Health and Safety: I- consentConditions to thewhich release may require from the emergency School-Based Oral Health Clinic to the NYC Department of Education and from the NYC Depart- 12. Express complaints about the care and services provided and to have the Center investigate ment of Education to the School-Based Oral Health Clinic, of oral health information outlined below in order to meet regulatory - Conditions which limit a student’s daily activity (Form 103S) such complaints, without fear of reprisal. A patient may express their concern verbally or in requ- Diagnosisirements of andcertain ensure communicable that the school diseases has (not information including HIVneededinfection/STI to protect and my other child’s confidential health and services safety. protected I understand by law). that this information- Health insurance will remain coverage confidential in accordance with Federal and State law and Chancellor’s Regulations on confidentiality: writing to the administrator. The Center is responsible for providing the patient or his/her InfoMy signaturermation to on Protect page 1Healthof this and form Safety also: gives my consent to Smile New York Outreach, LLC to contact other providers that have designee with a written response within 30 days if requested by the patient indicating the -examinedConditions my which child may and require to obtain emergency insurance information. findings of the investigation. The Center is also responsible for notifying the patient or his/her - Conditions which limit a student’s daily activity (Form 103S) -TimeDiagnosis Period of During certain Which communicableRelease diseasesof Information (not including is Authorized HIV infection/STI: and other confidential services protected by law). designee that if the patient is not satisfied by the Center’s response, the patient may -FromHealth: Date insurance that form coverage is signed on opposite page complain to the New York State Department of Health’s Office of Health Systems MyTo: signatureDate that on studentpage 1 isof nothis longer form enrolled also gives in the my S consentchool-Based to Smile Oral HealthNew York Clinic Outreach, LLC to contact other providers that have Management by calling 1-800-804-5447. examined my child and to obtain insurance information.

Time Period During Which Release of Information is Authorized: 13. Privacy and confidentiality of all information and records pertaining to the patient’s treatment. From: Date that form is signed on opposite page To: Date that student is no longer enrolled in the School-Based Oral Health Clinic 14. Approve or refuse the release or disclosure of the contents of his/her dental record to any healthcare practitioner and/or healthcare facility except as required by law or third-party payment contract. *OHCP = Oral Health Clinic Provider