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  • Dear Parents and Guardians,

    Community Care of West Virginia (CCWV) is happy to be able to offer health services in your child's schools, allowing you to continue with your life, and the child to get back to class more quickly. Schedules will be posted in each school and on our website so you know when we are there and how to reach us. Our licensed healthcare staff can treat flu, cough, fever, scrapes, check-ups, vaccines, as well as talking one-on-one about feelings or behaviors. These services work with your child's regular healthcare provider. If your child does not have a regular doctor, we can become their regular healthcare provider.

    CCWV accepts most insurance plans. All students can use the health services programs, even if they don't have insurance. If you have no insurance, we can assist you in enrolling for WV CHIP, Medicaid or a discount program.

    Parents are welcome to come to appointments with their child, but it is not required. We will try to call you before seeing your child. If we can't reach you, we will still take care of your child and update you afterward. You can see your child's health info or message the provider online through the Patient Portal at www.CCWV.org.

    Please fill out and sign the form, and send it back to school with a copy of your insurance card (if you have one) so your child can get care.

    Sincerely,

    Your School-Based Health Team at Community Care of West Virginia

     

    Enrollment Form may be downloaded and filled out on-line at www.CCWV.org

    CONTACT INFORMATION:

    Community Care of West Virginia

    37 West Main Street, Buckhannon, WV 26201

    (304) 473-5600

     

    For assistance outside regular hours of operation, including medical questions and/or prior to a visit to the ER, please call 888-557-2298.

  • SCHOOL-BASED HEALTH CENTER (SBHC) ENROLLMENT

    SCHOOL-BASED HEALTH CENTER (SBHC) ENROLLMENT

  • Student's Date of Birth*
     - -
  • Select one*
  • Ethnicity Non-Hispanic*

  • Parent/Guardian Information

  • Consent to text*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • The Health Center will make every attempt to contact you if your child needs to be sent home from school due to illness or injury. In case you are unavailable to be reached, please list the emergency contact(s) who CCWV may call and who have been granted your permission to pick up your child.

  • If we are unable to reach you, who should we call?

  • Format: (000) 000-0000.

  • Insurance Information:

    please attach copy of insurance/medical cards
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  • Format: (000) 000-0000.

  • If insurance coverage exists, please list the policy holder's name, date of birth, and Social Security number

  • Date of Birth
     / /

  • Medical Information

  • Does your child have any medication, food, or latex allergies*
  • Does your child take any medications?*
  • Has your child had any surgeries?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • In-School Services

    The Health Center has my permission to administer at no charge the following over-the-counter medications at the discretion of the medical provider.

  • Please check
  • My child has had a complete physical (well child) exam in the past year*
  • Date
     - -
  • Would you like us to complete their physical (well child) exam at the SBHC?*

  • (CCWV will contact you prior to performing this exam to discuss any health issues or concerns you may have in regards to your child.) ***Please note, a sports physical is not a well child exam.

     

    The Health Center can provide your child with the required immunizations for school along with the recommended immunizations by the Center for Disease Control (CDC). These immunizations can be given at no cost to you through the Vaccines for Children Program (VFC) or billed through your insurance which normally covers preventative services, i.e. immunizations, at 100%. CCWV will check with your insurance carrier on coverage of immunizations prior to being given.

  • I give permission for the school to share their immunization records with CCWV for the purpose of obtaining the the most complete immunization records possible*

  • The Health Center will attempt to contact you prior to your child receiving immunizations; however, if CCWV is unable to reach you, your child will be given a note to bring home with the immunization(s) given.

    No immunizations will be given without your permission. Please check the following:

  • *
  • Date*
     / /

  • Please review the information below and acknowledge your agreement

    • I give permission for my child to be treated by the school-based health staff (Community Care of West Virginia, Inc.). A brief history will be conducted during initial visit with provider.
    • I understand services may include medical services.
    • I understand services may include behavioral health services. I undrstand services may include telehealth.
    • I understand services may include dental services (in certain locations)
    • I certify that the information provided is accurate to the best of my knowledge. I understand that providing incorrect information can be dangerous to the student/patient's health. I will contact SBHC staff if any of the child's medical history or information changes.
    • I agree that messages can be left for me on the telephone number provided in the parent/guardian information section of this form.
    • I have reviewed CCWV's Notice of Privacy Practices at www.ccwv.org
    • Release of Information and Payment Authorization: I authorize the release of any medical or other information necessary to process my claim. I also authorize payment of medical benefits to Community Care of West Virginia, Inc. for services provided.
    • Consent and Acknowledgment of Privacy Practices: I consent to the use and disclosure of my protected health information by CCWV to any person or organization for the purpose of carrying out treatment, obtaining payment or conducting certain healthcare operations. Protected health information used or disclosed by CCWV may include HIV/AIDS related information, psychiatric and other mental health information, and drug and alcohol treatment information, as long as such information is used or disclosed in accordance with State and Federal law which may require that I provide specific authorization. I understand that information regarding how CCWV will use and disclose my information can be found in CCWV's Notice of Privacy Practices. I understand that this consent is effective as long as CCWV maintains my protected health information.
    • Authorization for Exchange of Health and Education Information: I hereby authorize CCWV to exchange health and education records (including immunization records) with my child's school district for the purpose of providing care and treatment to my child, if applicable.
    • Authorization for Exchange of Health Information: I hereby authorize CCWV to exchange health records (including immunization records) with my child's Primary Care Provider (PCP) for the purpose of continuity of care and treatment of my child.

     

    This authorization is valid throughout all years my child is enrolled in school or until I revoke it. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that health records if received by the school district may not be protected by the HIPAA Privacy Rules, but will become education records protected by the Family Educational Rights and Privacy Act (FERPA). I agree that a copy of this authorization is as valid as the original.

    By signing below, I understand and acknowledge the following:

    1. I have read and the understand this consent: and, 

    2) I have reviewed CCWV's Notice of Privacy Practices currently in effect. 

    3) I accept responsibility for payment of charges incurred for any services rendered to me or my dependents.

  • Date*
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