School-Based Health Center Forms

Bassett School-Based Health Center (SBHC) Forms

New Enrollments

Information Before Completing the Initial Enrollment Form(s)

• Initial Enrollment Letter to Parents / Guardians
• Guide to Completing SBHC Enrollment Forms

New Enrollment Forms to Complete

For the webform version of the initial enrollment form, just click on the below link, complete the form, and our team will let know if we need any additional information!

For the PDF versions, please print out the forms, complete them, and either mail them or deliver them in-person to the School-Based Health Center that you'd like to enroll in.

Electronic Webforms:

• Combined Initial Enrollment Webform
  • Please note that if your student is not a current Bassett Healthcare Network patient, you will also need to complete the PDF Authorization for Medical Record Release form.
  • If you need to save & continue this webform at another time, click the "Save and Resume Later" button at the bottom of each section.

PDFs:

• Combined Initial Enrollment PDF Form
• Authorization for Medical Record Release
  • The Authorization for Medical Record Release form is only required if the student is not a current Bassett Healthcare Network patient.
  • To submit your completed Authorization for Medical Record Release form, you can either mail it or drop it off at your SBHC.

Important Notes on Completing the Initial Enrollment Forms

• If you're enrolling in School-Based Health for more than one student, please complete separate enrollment forms for each student.
• If the student does not have health insurance, there is no need to complete the "Health Insurance Information" section on page one.
• Signatures on page two are both required to complete your enrollment application.
• If you check 'No...' / 'We do not...' to the "Dental Enrollment" & "Dental Insurance" sections on page three, there is no need to complete the rest of that page.

Frequently Asked Questions about Bassett's SBHCs

Have questions about our School-Based Health Centers? Visit our FAQ page for more information.