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 Date of Birth: 


YES, I give permission for a registered nurse and/or nurse practitioner employed by Big Sandy Health Care to examine and treat my child in his/her Floyd County school.

CONSENT TO TREATMENT: I authorize the examination and the rendering of diagnostic procedures and medical treatment by the Big Sandy Health Care registered nurses and/or nurse practitioner as they may, in their professional judgment, deem necessary or beneficial for my child. I understand that this consent to treatment includes treatment and health services provided in Floyd County schools by a Big Sandy Health Care registered nurse and/or nurse practitioner, including but not limited to, screenings, assessments, examinations, first-aid, injections and over-the-counter and prescribed medications.

I understand that the Big Sandy Health Care registered nurse and/or nurse practitioner providing examination and care of my child in the school may determine that further treatment is needed beyond that which can be performed at the school. I understand that I may need to take my child to a clinic, physician’s office or other facility in order to obtain all the treatment needed.

RELEASE OF INFORMATION:  I authorize Big Sandy Health Care, Inc. and its staff to release pertinent information from my child’s medical record to Floyd County school personnel on a need-to-know basis and to any insurance company or third-party payer that may be responsible for the payment of fees for the services rendered. I understand that release of my child’s information for any reason other than that necessary to secure payment for services rendered requires me to sign an additional authorization.

PAYMENT AUTHORIZATION:  If my child’s treatment is covered by a third party payer, such as Medicaid or health insurance, I hereby authorize payment of the benefits directly to Big Sandy Health Care. I understand that I will NOT be held responsible for payment for services provided by Big Sandy Health Care personnel in Floyd County schools.


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