Download Tiger Talk - Harmony Science Academy

Tiger Talk
Harmony Science Academy
ATTENTION ALL STUDENTS:
Read books in the summer and you could win a PIZZA & DANCE
PARTY!
1. Find a good book at home, at the public library, at a book store or
at our HSA library.
The HSA library will be open every Friday from
June 4th – June 25th
Harmony Science Academy
May 11th, 2016
Our next
Rundberg Educational
Advancement District
Day is Tuesday, May
17th.
12pm-3pm
Wear your READ
shirts and jeans.
2. Read the book.
3. Fill out a book review. Your teacher will give you copies of the book
review form.
4. Turn in your book reviews to the front office during the summer
or to your teacher next year.
Each book review will count as a raffle ticket. Three tickets will be
picked from each grade. The more books you read the more chances
to win!
2015-2016 Admin Team
 Principal: Kyle Borel
kborel@harmonytx.org
 Assistant Principal Academics K-4th:
Ayse Karabay
akarabay@harmonytx.org
 Assistant Principal Academics 5th-8th:
Yasin Ozkilic
yozkilic@harmonytx.org
 Assistant Principal Discipline :
Dana Ramos
djramos@harmonytx.org
Inside this issue:
May is National Armed Forces Month. Show your support for our
military by wearing RED, WHITE and BLUE or anything patriotic
and jeans for $1 on Thursdays for the month of May.


Summer Reading



3rd-5th Grade Luau


Summer Camps
Wear RED, WHITE,
and BLUE
VIP Island RSVP
Character Corner
Successful Smiles
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Character Corner
Harmony Science Academy is developing a Character Education
Program to help build our future leaders. We encourage parents to
practice using our ‘WORD OF THE MONTH’ at home as we practice
the skill at school. Harmony’s word of the month for May is
ENDURANCE
ENDURANCE:
Endurance is defined as
the act of working very
hard without stopping,
even in the face of
difficult situations.
Leadership Camp at Texas State University
Texas State University is organizing a Summer Leadership Camp for our middle school
students.
When: June 1st thru June 5th
Where: Texas State University
Who: 6 thru 8 grades
Camp activities include: Scuba Diving, Caving, River rafting, Water quality testing,
Invertebrate collection, Rock wall climbing, Glass bottom boat tour, Labs and activities for
learning; geology, biology, chemistry, ecology, and hydrology
Cost: $200
Please contact the Campus Engagement and Support Coordinator, Mr. Tice
(mtice@harmonytx.org)
Space is limited.
Location:
APPOINTMENTS AND QUESTIONS
Phone#: 512-270-9773 (English)
469-844-7758 (Spanish)
3100 S Congress Ave, #1 F
Austin, TX 78704
Correspondence Address:
2541 S IH 35, STE 200-140
Round Rock, TX 78664
Email: info@successfulmilesoftexas.org
I _______________________________________give permission for my child to participate in the Onsite Mobile Dental aspect
Print Full Name
Of the Successful Smiles of Texas Oral Health Program. This consent is for preventative care which includes an exams, x-rays,
cleaning, sealants, and fluoride. By signing below I acknowledge that I have read the Notice of Privacy Practices on this flyer and
understand my rights as stated. I understand that Successful Smiles will bill my insurance or Medicaid at no cost to me, and my
child’s Medicaid Provider will be updated prior to the visit.
OPT-OUT OF PROGRAM:
My Child______________________________________ will not participate in the Onsite Mobile Dental Oral Health Program.
Parent/Guardian Signature___________________________________________________________
Date___________________________
Signature
STUDENT INFORMATION:
_____ MALE _____FEMALE
Name: ___________________________________________________
(first, m, last)
Child’s School: __________________________________________
Teacher: _____________________________________Grade: _____
Date of Birth :_____________________________________________
PARENT ACCOMPANIMENT
(For Students Under 15 Years Of Age)
Child’s SS#:_______________________________________________
Parent’s Name (first, last):____________________________________
Appointments: Check the day and time you can be there.
Address: _________________________________________________
The best day of the week for me to accompany my child is:
City/State/Zip:_____________________________________________
___ Monday ___ Tuesday ___Wednesday ___Thursday ___Friday
Home Phone #: ____________________________________________
___ Anytime OR Indicate Preferred Time ________________.
Cell or Work #:____________________________________________
If I am NOT able to accompany my child to the dental visit,
I give Harmony Public School my consent to allow my child to
participate as allowed under the Family Code guideline 32.001(a).
Check one of the following:
___My child has no insurance
___My child has regular insurance
___My child has Medicaid: Ch eck wh ich k ind of Me d ica id .
____Chip ____Superior ____MCNA ____DentaQuest
_______________________________________________________
Parent/Guardian
nt/Guardian Signature
PARENTS WITH REGULAR DENTAL INSURANCE
Please fill out the information below:
Other _______________________________________________
Child’s Medicaid #: ________________________________________
Medical/Dental Information:
Does your child have a specific dental problem? Y / N If so, explain.
_________________________________________________________
Primary Insured’s name:__________________________________
Relationship to Child:______________________________________
Primary Insured’s Birth date: ________________ ______ _________
Month
Date
Year
Is your child under a Physician’s Care now? Y / N If so, why?
_________________________________________________________
Address:_________________________________________________
Is your child taking medication now? Y / N
What kind?
_________________________________________________________
Home Phone #:___________________________________________
Is your child allergic to any medications or substances? Y / N If so,
what?_____________________________________________________
Cell or Work #:____________________________________________
Does your child have a mental or physical disability? Y / N
(describe)__________________________________________________
Has your child ever had any of the following? (circle all that apply)
ADD/ADHD, Bleeding Disorder, Hepatitis, Learning Disorders,
Diabetes, Latex Allergy, Asthma, Epilepsy/Seizures, Psychiatric Care,
Autism Spectrum, Heart Problems, Tuberculosis, Rheumatic Fever,
Other: ____________________________________________________
Home
City/State/Zip Code
SS# (not child’s):__________________________________________
Employer: _______________________________________________
Dental Ins Company Name:_________________________________
Insurance Company Phone #:________________________________
Subscriber #:_____________________________________________
HIPPA-NOTICE OF PRIVACY Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION PLEASE REVIEW IT CAREFULLY.
YOUR HEALTH INFORMATION-This notice applies to the information and records
we have about you, your health, health status, and the services that you receive
from Successful Smiles Program. Your health information may be in the form of
written or electronic records or spoken words, and may include information
about your health history, symptoms, examinations, diagnoses, procedures,
prescriptions, and related billing activity. We are required by law to give you this
notice. It will tell you about the ways in which we may use and disclose health
information about you and describes your rights and our obligations regarding
the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU-We may
use and disclose health information for the following purposes:
• For Treatment-We may use health information about you to provide you
with medical treatment or services. We may disclose health information about
you to doctors, nurses, technicians, staff or other personnel who are involved in
taking care of you and your health.
• For Payment-We may use and disclose health information about you so that
the treatment and services you receive with Successful Smiles Program may be
billed and payment may be collected from an insurance company or a third
party. For example, we may need to give your health plan information about a
service you received here so your health plan will pay us or reimburse you for
the service.
SPECIAL SITUATIONS-We may use or disclose health information about you for
the following purposes, subject to all applicable legal requirements and
limitations:
• To Avert a Serious Threat to Health or Safety.
• Required By Law. We will disclose health information about you when
required to do so by federal, state or local law.
• Health Oversight Activities-We may disclose health information to a health
oversight agency for audits, investigations, inspections, or licensing purposes.
YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU-You have the
following rights regarding health information we maintain about you:
• Right to Inspect and Copy. You must submit a written request to our office in
order to inspect and/or copy records of your health information. If you request
a copy of the information, we may charge a fee for the costs of copying, mailing
or other associated supplies.
• Right to Amend. If you believe health information we have about you is
incorrect or incomplete, you may ask us to amend the information.
• Right to an Accounting of Disclosures.
• Right to Request Restrictions.
• Right to Request Confidential Communications.
• Right to a Paper Copy of This Notice.
If you believe your privacy rights have been violated, you may file a complaint
COMPLAINTS: You will not be penalized for filing a complaint.
with our office or with the Secretary of the Department of Health and
Human Services at:
Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
Phone: (800) 368-1019
To file a complaint with Successful Smiles, call 512-270-9773.
Oficina:
PARA CITAS Y PREGUNTAS:
Número: 512-270-9773 (Ingles)
469-844-7758 (Español)
3100 S Congress Ave, #1 F
Austin, TX 78704
Correo Electrónico:
info@successfulmilesoftexas.org
2541 S IH 35, STE 200-140
Round Rock, TX 78664
Correo:
Yo _______________________________________doy permiso para que mi hijo /a que participe en el aspecto del programa
Escriba Su Nombre Completo En Letra de Molde
Successful Smiles de Texas que también incluye exámenes, radiografías, limpiezas, selladores dentales y de enviar la factura a mi
Seguro o Medicaid. Al firmar abajo yo reconozco que he leído el Aviso de Prácticas de Privacidad en este folleto y entiendo mis
derechos. Autorizo a Successful Smiles que cambie mi proveedor de servicios dentales a Medicaid solamente para esta visita.
OPTAR POR NO
Mi Hijo (a) ___________________________________ no participará en el programa de Successful Smiles de Texas.
Firma de Padre o Guardián ____________________________________________________________ Fecha______________
INFORMACION DEL ESTUDIANTE
_____NIÑO _____NIÑA
Escuela:__________________________________________
Nombre Completo: _________________________________________
Maestra:__________________________ Año Escolar:_____
Fecha de Nacimiento: _______________________________________
Seguro Social: __________ _______ ___________________________
ACOMPAÑAMIENTO DE LOS PADRES
(Para Estudiantes Menor de 15 Años)
Nombre de la Madre o Padre:__________________________________
CITAS: Marque el día y la hora que más le conviene.
Dirección:_________________________________________________
Cuidad: _____________________Estado/Código: _________________
Teléfono (Casa):____________________________________________
Celular o Trabajo:___________________________________________
Marque uno de los siguiente:
___ Mi hijo/a no tiene Seguro
___ Mi hijo/a tiene Seguro regular
____Superior ____MCNA
___ A cualquier hora O note la hora Preferible ______________.
En el caso que no puedo acompañar a mi hijo/a a la visita dental,
le doy a la Escuela Pública Harmony mi consentimiento para que
participe mi hijo de acuerdo con la Directriz Código de Familia
32.001a).
__________________________________________________
Firma de Padres:
Padres:
___ Medicaid: Marq ue el S egu ro q ue s e ap liq ue .
____Chip
El mejor día de la semana para acompañar mi hijo/a es:
____ Lunes _____Martes ____Miércoles ____ Jueves ___ Viernes
INFORMACION DE PADRES CON SEGURO DENTAL
____DentaQuest
Por Favor Llene Lo Siguiente:
Otro: _____________________________________
Nombre del Asegurado Primario:_________________________
Numero de Medicaid del niño/a:______________________________
Información Medico/Dental:
Relación al Niño/a:______________________________________
Fecha de Nacimiento del Primario:__________________________
¿Tiene su hijo/a un problema dental especifico? No Si (explique)
_________________________________________________________
Mes
Día
Año
Dirección:_____________________________________________
Número de la casa
Si su hijo/a está bajo el cuidado de un medico, explique la razón?
_________________________________________________________
Cuidad/Estado/Código
Numero Telefónico de Casa:_______________________________
¿Está su hijo/a tomando medicamentos? ¿Que tipo?
_________________________________________________________
Celular o Trabajo:_______________________________________
¿Está su hijo/a alérgico/a algún medicamento? No Si Que tipo?
_________________________________________________________
# Seguro Social (del primario):_____________________________
¿Tiene su hijo tiene una discapacidad mental o física? No Si
(describe)_________________________________________________
Ha tenido su hijo/a cualquiera de los siguientes? (circule los que
aplican) TDA/TDAH, Enfermedad hemorrágica, Hepatitis, Trastornos de
aprendizaje, Diabetes, Alergia al látex, Asma, Epilepsia/convulsiones,
Cuidado psiquiátrico, Espectro de autismo, Tuberculosis, Problemas del
corazón, Fiebre reumática, Otra_________________________________
Empleado Por:__________________________________________
Nombre de la Seguranza:__________________________________
# Telefónico de la Seguranza:______________________________
# del Suscriptor:_________________________________________
# del Grupo_____________________________________________
HIPPA-NOTICE OF PRIVACY Practices
ESTE AVISO DESCRIBE CÓMO LA INFORMACIÓN MÉDICA SOBRE
USTED PUEDE SER USADA Y REVELADA Y COMO USTED PUEDE
TENER ACCESO A ESTA INFORMACIÓN. POR FAVOR LEA CUIDADOSAMENTE
SU INFORMACIÓN MÉDICA - Este aviso se aplica a la información y los registros
que tenemos de usted, su salud, estado de salud, y los servicios que usted
recibe de Successful Smiles Program. Su información de salud puede estar en
la forma de registros escritos o electrónicos o palabras habladas, y puede
incluir información sobre su historial de salud, síntomas, exámenes, diagnósticos, y procedimientos. Estamos obligados por ley a darle este aviso. Se le
informará acerca de las maneras en que podemos usar y revelar información
médica acerca de usted y describe sus derechos y nuestras obligaciones con
respecto al uso y divulgación de dicha información.
COMO PODEMOS USAR Y REVELAR INFORMACIÓN SOBRE SU SALUD - Podemos
usar y divulgar su información médica para los siguientes propósitos:
• Para Tratamiento - Podemos usar información médica sobre usted para
proporcionarle tratamiento o servicios médicos. Podemos revelar información
médica acerca de usted a médicos, enfermeras, técnicos, personal u otro
personal que esté involucrado en el cuidado de usted y su salud.
• Para el Pago - Podemos usar y revelar información médica acerca de usted
para que el tratamiento y los servicios que usted recibe del Programa
Successful Smiles puedan ser facturados y el pago puede ser obtenido de una
compañía de seguros o un tercero. Por ejemplo, es posible que necesitemos
darle a su plan de salud acerca de un servicio que usted recibió aquí, así que su
estado de salud plan nos pague o le reembolse a usted por el servicio.
SITUACIONES ESPECIALES - Podemos usar o divulgar información sobre su salud
para los siguientes propósitos, sujeto a todos los requisitos legales aplicable.
• Para evitar una amenaza seria para la salud o la seguridad
• Requerido por la ley - Vamos a revelar información sobre su salud cuando
sea requerido por la ley federal, estatal o local.
• Las actividades de supervisión de la salud - Podemos revelar
información médica a una agencia de supervisión de salud para auditorías,
investigaciones, inspecciones, licencias o propósitos.
Sus DERECHOS CON RESPECTO A LA INFORMACIÓN SOBRE SU SALUD-Usted
tiene los siguientes derechos sobre la información médica que mantenemos
sobre usted:
• Derecho a inspeccionar y copiar.
• Derecho a enmendar
• Derecho a una Contabilidad de Revelaciones.
• Derecho a solicitar restricciones
• Derecho a solicitar Comunicaciones Confidenciales.
• Derecho a una copia impresa de este aviso
QUEJAS - Usted no será penalizado por presentar una queja.
Si usted cree que sus derechos han sido violados, puede presentar una queja
con nuestra oficina o con el Secretario del Departamento de Salud y
Servicios Humanos a la:
Para presentar una queja con Successful Smiles, llamen al 469-844-7758.
Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, TX 75202
Teléfono (800) 368-1019