Microsoft word - hcc letter new 2013-14

March 2013
Dear Families,
Riverview’s Health Care Center welcomes our new and returning students for the 2012-
2013 school year. In preparation, you will find the paperwork that needs to be completed
prior to enrollment in the summer and/or fall program. This must be done annually and,
therefore, includes returning students. As required by the Commonwealth of
Massachusetts, the Department of Elementary and Secondary Education, and the
Department of Public Health, it is mandatory that all the forms are returned to the Health
Care Center before your child begins the summer or fall program (i.e., May 1st for the
summer program and July 1st for the fall program.)
Prior to your son/daughter’s arrival, it is essential that we have proper authorizations and
completed forms in place. Only with your support can we be best prepared to manage
any health care needs or emergencies that might arise. The School will not accept
students who are without appropriate medical insurance and/or updated
documentation. Parents will have to remain with their child until the paperwork is
complete. Please mail or fax forms as they are completed. In addition, evidence of all
required vaccinations must be documented on Form 5A, or submitted on a printout from
your physician’s office.
Please feel free to contact the Health Care Center if you have any questions or concerns.
Sincerely,
Cate MacFarland, RN
Director of Health Care Services
Enclosures
RIVERVIEW SCHOOL
Medical Forms Checklist
2013 - 2014
The following forms must be completed every year.
(Keep a copy of these forms for your files.) Medical Release (To enable HCC staff to seek medical attention, i.e., medical appointments, emergencies) Medical Emergency Contact Information Parent/Guardian's signature required Medical Care Authorization (Return with a copy of the front and back of insurance and/or prescription card) Authorization to Dispense Prescription Medication Parent/Guardian's signature required PharMerica
MUST BE COMPLETED EVEN if you use another pharmaceutical provider
Parent/Guardian's signature required
Health Care Form for New or Returning Students (Mandatory annual update) Record of Immunizations (Mandatory for new students. Updates as needed for returning students if received booster or vaccination) May be submitted as a printout from your physician’s office. Doctor’s signature required Health Care Providers Examination (Mandatory Annual Update) Doctor’s signature required. May be submitted as a printout from your physician’s office. Approval for Activities (Permission form for school activities no restrictions/limitations due to health conditions) Parent/Guardian signature required & Doctor’s signature required Dental Certificate (Mandatory annual update) Dentist's signature required Authorization to Dispense Over-the-Counter Medication Parent/Guardian's signature required & Doctor’s signature required Medication Order Form Doctor’s signature required Doctor’s Information Sheet (To facilitate communication with physicians currently treating the student) \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment RIVERVIEW SCHOOL Medical Release 2013-2014

Please list the name(s) and number(s) for any person(s) you want to be notified in case of a medical emergency other than parent/guardian or licensed
Please include a copy of insurance card and prescription card (both sides).
CONSENT TO OPERATE, ANESTHETICS AND OTHER SURGICAL AND MEDICAL TREATMENT AND SERVICES

Although every effort will be made to contact the listed parent/guardian, it must be acknowledged that there may be occasions when my child/ward will require operative and/or
related medical treatment on an emergency basis or without there being time for me to be contacted or consulted. I hereby consent to such operative or other medical treatment
reasonably necessary in the opinion of the attending physician or physicians, for the well-being of my child/ward. Further, I authorize the attending physician or physicians, or
emergency care staff, to carry out the necessary treatment.
I authorize the personnel in charge of my child/ward at the Riverview School, Inc. to communicate this consent and release form on my behalf to such hospitals, medical doctors or
emergency care staff as may be required. A photocopy of the Release shall be considered valid for this purpose.
I hereby waive and release any claim I have individually or on behalf of my child/ward against the Riverview School, Inc., its agents, servants and employees in connection with any
liability arising out of the medical treatment rendered.
Please list ALL MEDICAL DIAGNOSES:
Does your child have any drug, food or environmental allergies? Yes No (if yes, specify): \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form 1 Medical Release-Blank-2013-14.doc F O R M 2 RIVERVIEW SCHOOL Medical Care Authorization
2013 - 2014
In order to better serve your son/daughter, please check off below how you would like the HCC to proceed when your child requires non-emergency medical care in order to comply with your insurance
Please note: The HCC does call parents AFTER any non-routine visits to the Doctor.
Please call me BEFORE my child is taken to the Doctor so I can arrange for "pre-approval." My child may go to the Doctor without "pre-approval." I will pick up my child and take him/her to his/her physician at home if needed. My child is authorized to see the following physician in the school's area: I understand that I am legally responsible for any balance that is not covered by insurance. The parent or guardian must make all insurance arrangements and pre-approvals. If you have any questions regarding the above, please contact the Health Care Center staff. Please provide a copy of your child's insurance and prescription
cards (both sides) to be kept on file in the Health Care Center.
Authorization to Dispense Prescription Medication
2013 - 2014
By my signature below, I approve to have the school nurse or school personnel designated by the school nurse to administer the prescription medication and health care services. The completed prescription medication administration record(s) shall be filed in the student's cumulative health record.
Parent/Guardian Signature:
By my signature below, I acknowledge that a prescription medication administration plan must be established with the school nurse in collaboration with the parent or guardian. Whenever possible, this plan shall involve the student who understands the issues of medication administration in the decision-making process and his/her preferences respected to the maximum extent possible. If appropriate, the medication administration plan will be referenced in any other health or educational plan developed pursuant to Massachusetts (i.e., 766) or Federal (i.e., IDEA or Rehabilitation Acts of 1973) laws. \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment PharMerica Enrollment Form
2013 - 2014
PharMerica customer service # is 1-800-242-0978 x5974
(9:00 am - 5:00 pm ET)
 For all medications  For emergency medications only Student’s primary payor type. Please denote primary with an (*) asterisk.
List all other types of coverage with necessary information.
Responsible Party (We need the information regardless of the payor type.)
\\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment RIVERVIEW SCHOOL
Health Care Form for New Students
2013 - 2014
MEDICAL HISTORY

Current Medical Diagnosis:
Past medical and surgical history (operations, hospitalizations, serious illnesses). Include dates: Does your child have a history of or a current psychiatric/psychological diagnosis? Please explain: Is your child prone to any illnesses? (e.g. frequent ear infections, ingrown toe nail problems, etc.): Does your child receive allergy injections? SEIZURE DISORDERS
Does your child have a seizure disorder? Does he/she have any warning signs and/or "aura"? Describe type and duration of seizures, and date of last known seizure: DIET & NUTRITION
Is your child on a medically restricted diet? YES  NO If yes, please specify why and provide a detailed list of what your child can and cannot eat. Also, please provide information about foods your child does not eat. (Use a separate sheet of paper if necessary.) Has your child had problems with eating disorders, e.g., binging, purging, refusing to eat? Any other health care concerns that we should be aware of at this time (e.g., unable to participate in physical education classes, etc.)? Describe any treatment strategies or anecdotal information that would assist our staff in meeting your child's medical/health needs: PERSONAL HYGIENE
Please explain if your child will need assistance with any of the following. Skin If not, is your child aware of body changes? Is your child afraid of loud noises? YES  NO  Does your child have difficulty falling asleep? Does your child have difficulty swallowing pills? YES  NO  If yes, please provide liquid medications. Does your child require lab work? YES  NO  If yes, a physician’s written order is required. Is your child afraid of doctors? YES  NO  Will your child be able to let staff know when they are not feeling well? YES  NO  \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form 4 F O R M 5 A / Riverview School
Fax: 508-833-7004
Certificate of Immunization / 2013-2014
Date of Birth: / /
(If combination vaccine is administered, please indicate vaccine type (e.g., DTaP-Hib, etc.)
Date/Vaccine Type
Date/Vaccine Type
Hepatitis B
Rotavirus
Measles, Mumps,
Rubella (MMR, MMRV)
Diphtheria, Tetanus, 1
Pertussis
Varicella
Meningococcal
Influenza
Haemophilus
Influenzae type b
Hepatitis A
Papillomavirus
Serologic Proof of Immunity
Check One
Chickenpox History
Check this box if this person has a physician-certified reliable history of chicken pox. Date: ___________________________  physician interpretation of parent/guardian description of chickenpox  physical diagnosis of chickenpox, or * Must also check Chickenpox History box. I certify that this immunization information was transferred from the above-named individual’s medical records.
Doctor or nurse’s name (please print): Form revised 01/10 Updated 01/13 \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form 5A Certificate of Immunization 2013-14.doc RIVERVIEW SCHOOL FORM 5B
Fax: 508-833-7004
Health Care Provider’s Examination
2013-2014
Current Health Issues
Asthma Asthma Action Plan  Yes  No Current Medications
(If relevant to the student’s health and safety.) A separate medication order is needed to administer medications. Physical Examination
(Check = Normal. If abnormal, please describe) Screening
Laboratory Results
The entire examination was normal 
Targeted TB Skin Testing
 Med-to-High Risk (exposure to TB; born, lived, traveled to TB endemic countries; medical risk factors) Date of PPD This student has the following problems that may impact his/her educational experience:
 Vision  Hearing  Speech/Language  Fine/Gross Motor Skills  Emotional/Social  Behavior  Other Comments/recommendations  Yes  No This student may participate fully in the school program, including physical education and competitive sports. If no, please list restrictions  Yes  No Immunizations are complete. If not, give reason. Please attach Massachusetts Immunization Information System Certificate or other complete immunization record. Please attach additional information as needed for the health and safety of the student. \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form 5B Health Care Providers Exam 2013-14.doc RIVERVIEW SCHOOL
Health Care Permission Form
2013 - 2014
 This student may participate fully in school activities. He/She has no restrictions/limitations due to health conditions.  This student may participate in all competitive/intramural athletic/activities without  This student may not participate in the following activities listed below. Please specify (e.g., all amusement park rides, physical education, competitive sports and swimming activities.) Form revised 01/11Updated 01/13 \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form RIVERVIEW SCHOOL
Dental Certificate
2013 - 2014
A report of an annual examination is required for each student by the Massachusetts Department of Early Education and Care. This statement must be signed by the family dentist and then returned to Riverview School. Efforts should be made to have all dental work done that is necessary with: 1. The mouth as clean as possible with special attention to food debris and tartar. 3. Attention given to all pits and fissures in deciduous and permanent teeth. The final opinion concerning any mouth conditions rests with the family dentist. TO BE COMPLETED AND SIGNED BY FAMILY DENTIST:
is receiving dental care from this office. has had all work done that is necessary at this time.  Yes Dentist's name, address and phone number (please print): ****A REPORT OF AN EXAMINATION IS NECESSARY EACH YEAR****
\\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form 6 Dental Certif 2013-14.doc RIVERVIEW SCHOOL
Authorization to Dispense Over-the-Counter Medication
2013 - 2014
The following is a list of over-the-counter (non-prescription) medications that have been approved by a physician for school use. These may be given at the discretion of the nursing staff, as needed. No child will receive a medication if contraindicated (i.e. past allergic reaction or existing medical condition prohibits use). If you DO NOT WANT your child to receive a medication listed below, please CIRCLE IT.
Bacitracin, Neosporin, Triple Antibiotic Ointment Tolnaftate, Chlortrimazole antifungal cream/powder Ear wax removal drops (Debrox or Colace drops) PLEASE NOTE: If your child takes ANY other over-the-counter product including dietary
supplements, which are not listed above, please add them in the space provided below. Without the
physician's signature, we will not administer any over-the-counter or dietary supplements.
Other:
 If your child requires a specific over-the-counter medication (e.g., Tylenol
Cold, Sudafed), please provide the medication to HCC and indicate above.
 We may use the generic equivalent of the medications listed above. Please indicate above if your child cannot receive the generic form of these medications.  This form must be signed by the parent/guardian and by the student's Primary Care Physician. It will become part of your child's records.  I understand that my child may receive an over-the-counter medication, if necessary, at the Physician's name and address (please print): Form revised 01/11 Updated 01/13 \\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment RIVERVIEW SCHOOL
Medication Order (Not a prescription)
2013 - 2014
Fax: 508-833-7004
Attention Licensed Prescriber: PharMerica is Riverview School’s pharmacy. The pharmacy will contact the prescriber on a
monthly basis for refills of controlled medications. All other medications will require prescriptions for the school year. Attention School Year Parents: In preparing for your child's arrival in September, please bring AT LEAST TWO (2) weeks of
medications including topicals, ear drops, eye drops, etc., as well as written prescriptions for these medications Attention Summer Program Parents: Please provide medications for the 5-week program.
Date of Birth:
Date of Order
Medication
Specific Directions
Frequency
\\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form 8 Medication Order 2013-14.doc RIVERVIEW SCHOOL
Doctor’s Information Sheet
Please include any medical doctors on this sheet who prescribe medications and/or provide care for your child.

Doctor’s Name:
\\rvs.local\Staff\Janse\HCC\HCC Forms\Medical Forms\2013-14 Enrollment Forms\Form 9 Dr Info Sheet 2013-14.doc

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