How can I get my child a FREE eye exam? TURN THE PAGE AND FIND OUT

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After filling out this form, please return it to the school nurse or health clinic as soon as possible. 

Eagles Eye Mobile Permission Form 

Good vision is important to do well in school!  Your child may get a free eye exam on the Eagles Eye Mobile.  If needed, your child will be given a free pair of eyeglasses.  If your child needs follow‐up care, you will be notified by a letter and you can work with your child’s school nurse/health clinic to set‐up an appointment at an eye specialist (ophthalmologist).  Your consent is needed to give these FREE services to your child.  

 I, ________________________________ am the parent/legal guardian of ________________________ (child’s name)  

and I give consent for him/her to participate in the Eagles Eye Mobile Program.     

Name of Child:  _________________________________________ Child Date of Birth:  _____________  (m/d/y)   

Sex: F M  Other:________ School:________________________________  Grade:  _______ Street Address: _______________________________________City: ______________________    State: ____  Zip: _____ 

*Phone #1:  ____________________      home        cell   Emergency Phone #2:  ____________________         home       cell 

Email: ________________________________  

*Main contact phone number.

Eye Health History: Is your child under the care of an eye doctor or specialist: YES NO Date of Last Visit:_______ Name of Doctor:__________________________ Phone:_________________________ Any known eye problems, past surgery, issues?________________________________________________________________________ Primary Care Doctor: __________________________________________ Name of Office: _____________________________________________________ Phone:_____________________

By signing this consent form, you agree to the following: • My child may get an eye exam from an eye doctor (either an optometrist or an ophthalmologist).  The exam may include eye drops,

which may cause short‐term dilation of my child’s eyes.

• Doctors or other health care providers on the Eagles Eye Mobile will give the results of my child's eye exam to the school nurse or clinic and to Eagles Charitable Foundation (ECF), so that my child's vision health record can be updated.  They will then be shared with me.

• I agree to get calls and text messages from ECF about my child’s health care at the phone number(s) listed in this consent. I understand that I may be charged for the calls or text messages by my cellphone carrier.

• The School District or Health Clinic can give my new contact information, such as name, address and phone number to the Eagles Eye Mobile, so that I can be contacted for follow‐up.

• I was given a copy of the Notice of Privacy Practices and read it.

• I have read this consent before signing it and I understand what it says.  I understand that I may take back my consent at any time by telling the Eagles Eye Mobile at 215‐339-6770. 

By checking the box below, I consent to the following: 

I grant permission to the Eagles Charitable Foundation, the charitable arm of the Philadelphia Eagles, to take pictures and/or video of my child and use my child’s name, photographs, voice and likeness for any and all promotional or commercial purposes without further compensation.  

_______________________________________________________   ___________________________

Printed Name of Parent/Legal Guardian   Relationship to the Child 

_________________________________________  ____________________ Signature of Parent/Legal Guardian Date

GROUP B Eagles Eye Mobile Program 2016‐2017 Expires December 2017 

Turn Over

☐ I do not want toreceive text messages.

☐ I do not want toreceive emails.

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PATIENT INFORMATION FORM Patient seen on Eagles Eye Mobile

After filling out this form, please return it to the school nurse as soon as possible. 

Medications: List all medications child is currently taking

Name of Medicine Dose/Strength How often do you give this medication to your

child?

Allergies: Please check all allergies that your child has and list reactions. Medicine ____________________________ Contact _____________________________ Food _______________________________ Contrast Dye _________________________ Latex _______________________________ Blood Products _______________________

Other Medical Problems. Has your child had or does your child have any of the following? Please explain if checked.

Heart Problems _____________________________ Seizures or other neurological problems ______________ Asthma or other breathing problems _____________ Developmental delay(s) ___________________________ Bleeding Problems ___________________________ Other _________________________________________

Premature Birth? YES NO

TO BE FILLED OUT BY SCHOOL NURSE  EAGLES EYE MOBILE STAFF (Autorefraction Slip Attached)

SCREENING RESULTS 

Already wearing glasses Not wearing glasses Glasses unavailable

Distance Vision Acuity:

Right:20/_____ Left:20/_____

Near Vision Acuity:

Right:20/______ Left:20/_____

Additional notes: ________________________________________________ ________________________________________________ ________________________________________________

**A student should only be referred to the Eagles Eye Mobile if acuity is 20/40 or worse in one or both eyes or there is another eye health concern.**

Page 3

For More Inform

ation If

you have

questions or

would

like additional

information, you m

ay contact our privacy officer:

Hospital Privacy O

ffice St. C

hristopher’s Hospital for C

hildren Erie Ave at Front Streets Philadelphia, PA 19134

(215)427-3812

Corporate Privacy O

ffice Tenet H

ealthSystem

13737 Noel R

oad, Suite 100 D

allas, TX 75240

We w

ill be happy to provide you with a m

ore detailed version of this N

otice. Simply ask the C

hief Privacy O

fficer for our full Notice of Privacy Practices.

If you believe your privacy rights have been violated, you can file a com

plaint by contacting the Chief

Privacy Officer

at the above

address and phone

number, or you can file a com

plaint directly with the

Secretary of

the U

.S. D

epartment

of H

ealth and

Hum

an Services.

Effective Date; R

evisions The effective date of this N

otice is April 14, 2003.

We reserve the right to change our privacy practices

and the terms of our N

otice at any time, as perm

itted by law

. We reserve the right to m

ake those changes effective for all health inform

ation that we m

aintain, even if w

e created or received it before we m

ade the changes.

Our privacy practices, as described in this N

otice, will

remain

in effect

until w

e change

this N

otice. W

henever we m

ake significant changes to our privacy practices, w

e will change this N

otice and make the

new N

otice available upon request.

ST. CH

RISTO

PHER

’S HO

SPITAL

FOR

CH

ILDR

EN

NO

TICE O

F PRIVAC

Y PR

ACTIC

ES

THIS N

OTIC

E DESC

RIB

ES HO

W

MED

ICA

L INFO

RM

ATIO

N A

BO

UT

YOU

MA

Y BE U

SED A

ND

DISC

LOSED

A

ND

HO

W YO

U C

AN

GET A

CC

ESS TO

THIS IN

FOR

MA

TION

. PLEA

SE REVIEW

IT CA

REFU

LLY.

Why You A

re Receiving This N

otice At the St. C

hristopher’s Hospital for C

hildren (St. C

hristopher’s), w

e are

comm

itted to

treating and

using protected health information about you in a

responsible manner. W

e are required by federal and Pennsylvania law

to treat

your health inform

ation confidentially. It is your right to have us do that. This N

otice describes

the privacy

practices of

St. C

hristopher’s, its employees, physician m

embers of

the medical staff and the allied health professionals

who practice at St. C

hristopher’s.

We have developed a Privacy C

ompliance Program

that

is directed

at protecting

the privacy

and confidentiality of your health inform

ation (“protected health inform

ation” or “PHI”). This N

otice of Privacy Practices describes the health inform

ation we collect,

how and w

hen we use or disclose that inform

ation, and

your rights

under our

Privacy C

ompliance

Program.

Understanding Your H

ealth Record

Each time you visit St. C

hristopher’s, we create a

record of your visit. Typically, this record contains your

symptom

s, exam

ination and

test results,

diagnoses, treatment, and a plan for future care or

treatment. The m

edical record is a valuable tool that serves a num

ber of purposes, such as: •

Planning your care and treatment

•C

omm

unicating with those w

ho provide you with

care or services; •

Allowing your insurer to verify that services bille d

were actually provided;

•Educating healthcare professionals;

•Providing

information

for our

planning and

marketing activities;

•Assessing our ow

n performance so that w

e cancontinue to im

prove our care and services.

Although the physical record that we create is the

property of St. Christopher’s, the inform

ation in it is about you, and it belongs to you. W

e want to help

you make inform

ed decisions about who has access

to your PHI.

Our Legal D

uty W

e are required by law to restrict the uses and

disclosures of your PHI. If there is a security breach

of your

PHI,

we

are required,

in certain

circumstances, to notify you. W

e are also required to give you this N

otice about our privacy practices, our legal duties and your rights concerning your PH

I. We

will follow

the privacy practices that are in this Notice

while it is in effect.

P a g e 4

Uses and D

isclosures of Your Health

Information

Highly Confidential H

ealth Information

Some

health inform

ation is

“highly confidential”

because it is specially protected under New

Jersey law

.

“Highly

confidential” inform

ation includes

treatment inform

ation about mental health or drug or

alcohol abuse

or dependence;

HIV-related

information;

tuberculosis inform

ation; and

genetic inform

ation.

We

are generally

not perm

itted to

disclose your

highly confidential

PHI

unless you

authorize us to do so. You may learn m

ore about w

hen w

e are

permitted

to disclose

your highly

confidential PHI w

ithout your permission by using the

contact information that appears on the back of this

pamphlet.

Treatment,

Payment

and H

ealth C

are O

perations Activities (“TPO”)

We m

ay use or disclose your PHI for TPO

purposes, w

ithout the need to get your written authorization. For

example, those w

ho are involved in your care and treatm

ent will have access to your PH

I. In order for us to receive paym

ent for the care we provide to you,

we w

ill need to tell your insurance company about

that care. We m

ay also use your PHI for our ow

n purposes,

such as

monitoring,

planning and

developing our care and services and educating our staff. W

e may also disclose or release PH

I from your

medical records for the TPO

activities of another healthcare provider or agency that is not affiliated w

ith us. W

e would release inform

ation about you only if it w

ere needed in connection with care or services that

have been or will be delivered to you (including

payment for such care or services).

Other U

ses and Disclosures Not R

equiring Your Authorization W

e may also use or disclose your PH

I to tell you about treatm

ent options or alternatives or health-related benefits or services that w

e think may be of

interest to you. We m

ay use and disclose your PHI to

provide you with appointm

ent reminders, such as

voicemail m

essages or postcards or letters. We m

ay disclose your PH

I to business associates, which are

individuals or organizations that perform certain key

functions or processes for us. Before we disclose

your PHI to our business associates, w

e require them

to give us written assurances that they w

ill safeguard and protect the privacy of your PH

I.

We

may

contact you

with

information

about St.

Christopher’s-sponsored

activities, including

fundraising programs and events, but w

e would only

use limited inform

ation about you for that purpose. You

have no

obligation to

respond to

these com

munications, and you m

ay choose not to receive them

in the future. W

e will disclose your PH

I when w

e are required to do

so by

law;

for health

oversight activities

conducted for or by governmental agencies; and for

public health activities, such as to report suspected child abuse, com

municable diseases or certain types

of injuries. If you are an organ donor, we m

ay release

your PH

I to

organizations that

handle transplants. W

e may use or disclose your PH

I for w

orkers’ com

pensation or

similar

programs

as perm

itted or required by law. W

e may use your PH

I for our research purposes, but only if w

e are sure that your privacy w

ill be protected. If you are or w

ere a mem

ber of the armed forces, w

e m

ay release

your PH

I to

military

comm

and authorities as required by law

. We m

ay use or disclose your PH

I in order to prevent or lessen a serious threat to your health and safety or the health and safety of som

eone else. If asked to do so, w

e m

ay release

your PH

I for

law

enforcement

purposes, if we are perm

itted to do so by law. W

e m

ay disclose your PHI to authorized federal officials

for purposes of national security. W

e may disclose your PH

I if we are directed to do so

by court order. In most circum

stances, we m

ay disclose your PH

I to a coroner or medical exam

iner, or to a funeral director. If you are an inm

ate, we m

ay release your PH

I to the correctional institution where

you are being housed, if required to do so by law.

Opportunity for You to Agree or O

bject W

hen possible,

we

will

give you

the option

of restricting or lim

iting our use or disclosure of your PH

I for certain purposes: •

For our

patient directory

(including letting

am

ember of the clergy know

of your religiousaffiliation);

•For the involvem

ent of your family or others in

your care or payment for your care;

•For disaster relief efforts.

Other uses and disclosures of your PH

I not covered by this N

otice will be m

ade only with your w

ritten perm

ission.

You can

revoke that

permission,

in w

riting; but if you do, we are unable to take back any

disclosures we already m

ade with your perm

ission.

Your R

ights R

egarding Your

Health

Information

You have the right to look at or get copies of your PH

I, with lim

ited exceptions. You must subm

it your request in w

riting to the person whose nam

e is on the back cover of this pam

phlet. We m

ay charge a fee to provide you w

ith copies. W

e may deny your request to look at or get a copy of

your PHI. If w

e do, we w

ill explain the reasons to you, and in m

ost cases you may have the denial review

ed. You

have the

right to

request that

we

make

corrections to your PHI. Your request m

ust be in w

riting, and it must explain the corrections to be

made. W

e may deny your request under certain

circumstances; and if w

e do, we w

ill explain the reasons to you. W

ith certain exceptions, you have the right to know of

the times w

hen we have disclosed your PH

I without

your authorization. We w

ill provide you with a listing

of those disclosures if you request it. If you request this listing m

ore than once in a 12-month period, w

e m

ay charge you a fee for the additional requests. You have the right to request that w

e restrict or limit

some of our uses or disclosures of your PH

I. We are

not required to agree to those restrictions. You have the right to request that w

e comm

unicate w

ith you about medical m

atters in a certain way or at

a certain location. For example, you can ask that w

e contact you only at w

ork or by mail. Your request

must be in w

riting, and you must tell us w

here or how

to contact you. We m

ay require you to explain how

payments w

ill be handled under the alternative means

or location you request. If you received this N

otice on our website or by

electronic mail (e-m

ail), you have the right to receive this N

otice in written form

. To obtain a paper copy of this N

otice, use the contact information on the back

cover of this pamphlet.

FOR

QU

ESTION

S REG

AR

DING

YOU

R PRIVA

CY

RIG

HTS, U

SE THE C

ON

TAC

T INFORM

ATIO

N ON

TH

E BA

CK

COVER

OF TH

IS PAMPHLET.

PHILA

DELPH

IA\6163660\1 096233.000

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