Please read carefully, COMPLETE FORM, SIGN, and DATE. For any questions or concerns, please contact Big Sandy Health Care's Healthy @ School Program by calling (606) 263-6500.

I give permission for Big Sandy Health Care's qualified professionals to examine, test, and treat my child, as named above, either at their school or through telehealth services.

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.