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 CONSENT FOR MEDICAL TREATMENT
PLEASE READ BEFORE YOU SIGN
 
 
 
 
 Date of Birth: 

 

 CONSENT TO TREATMENT: YES, I give permission for nursing assistants, registered nurses, nurse practitioners and physicians employed by Big Sandy Health Care (BSHC) to examine and treat my child in his/her school. I understand that this consent to treatment includes treatment and health services provided face-to-face by BSHC employed nursing assistants or registered nurses onsite in the school.

I understand that in some situations the nursing assistants or registered nurses may arrange to have my child evaluated further by a BSHC nurse practitioner or physician. I understand such examination and treatment would take place, without my child leaving the school, through use of telehealth technology that includes real-time interactive audio and video technology delivered through a secure connection with the nurse practitioner or physician. I authorize the examination and treatment provided of my child through telehealth technology that connects him/her through interactive audio and video technology with a nurse practitioner or physician who is located at a distant site.

I authorize the examination and the rendering of diagnostic procedures and medical treatment by the BSHC nursing assistants, registered nurses, nurse practitioners and physicians as they may, in their professional judgment, deem necessary or beneficial for my child. I understand that the treatment may include, screenings, assessments, examinations, first-aid and over-the-counter and prescribed medications ordered by a nurse practitioner or physician.

RELEASE OF INFORMATION: I authorize Big Sandy Health Care to release pertinent information from my child’s record to 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 information for any other reason requires me to sign an additional authorization.

PAYMENT AUTHORIZATION: If my child’s treatment may be 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 his/her school.

 



 
 

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