Big Sandy Health Care, Inc.'s (BSHC) Healthy@School program offers convenient, on-site health services for students and adults during the school day in select schools. With your permission, your child may receive a range of services, including: 

• In-person or telehealth visits with a licensed medical provider
• Testing for strep throat, COVID-19, and flu
• Immunizations
• Dental services such as screenings and cleanings
• Behavioral health support including counseling and mental health resources

 

 These services are designed to keep your child healthy, reduce school absences, and support their overall well-being and academic success.

Please review the information on the following pages carefully. Then, complete and submit the consent form to enroll your child in the BSHC Healthy@School program. 

If you have questions regarding the BSHC Healthy@School program, please contact 606-263-6500.

Consent for Medical Treatment

PLEASE READ CAREFULLY BEFORE SIGNING.

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.

Consent for Dental Treatment

PLEASE READ CAREFULLY BEFORE SIGNING.

For any questions or concerns, please contact Big Sandy Health Care's Healthy @ School Program by calling (606) 263-6500.

 

YES, I give permission for my child to be examined and treated by a Big Sandy Health Care dentist, dental hygienist, and staff at the school or on a Mobile Dental Unit located on school property.

1.    I understand that my child’s teeth will be examined by a qualified Big Sandy Health Care dentist.

2.    I understand that the dental exam may include the use of digital dental x-ray equipment (digital x-rays generally result in less radiation exposure than traditional film).

3.    I understand that preventive services, which may include cleaning and application of fluoride and sealants, may be provided by the dental hygienist without the presence of, but under general supervision of and according to a plan ordered by a dentist.

4.    I understand the examination may determine that more treatment is needed beyond that which can be performed at the school or on the Mobile Dental Unit. I understand that, if indicated, Big Sandy Health Care will assist in referring my child to another dentist.

5.    While all the individual dental records are held by Big Sandy Health Care as confidential, I understand that a list of children who need follow up dental treatment may be routinely provided to the school’s family resource center.

6.    If my child is insured by an Avesis plan, I give my permission for an Avesis representative to return to the school within 365 days to check my child's dental sealants (if applicable).

CONSENT TO TREATMENT: I authorize the examination of my child by a Big Sandy Health Care dentist, including the performance of diagnostic digital x-ray. I authorize the provision of preventive care procedures by a Big Sandy Health Care dentist, dental hygienist and staff, as may be necessary or beneficial.

RELEASE OF INFORMATION: I understand that the dental records and x-rays that are associated with my child’s evaluation and care are the property of Big Sandy Health Care. I authorize Big Sandy Health Care and its staff to release pertinent information from the patient’s record to any insurance company or agency which may be responsible for the fees for services rendered. In the event a Big Sandy Health Care dentist refers my child to another dentist, I authorize the release of my child’s dental records to that dentist (referral dentist). In addition, I authorize the referral dentist to release my child’s dental records to Big Sandy Health Care.

PAYMENT AUTHORIZATION: I hereby authorize insurance payment directly to Big Sandy Health Care of the benefits that might otherwise be payable to me. I understand that I will NOT be required to pay for services.

 

Consent for Behavioral Health Services

PLEASE READ CAREFULLY BEFORE SIGNING.

For any questions or concerns, please contact Big Sandy Health Care's Healthy @ School Program by calling (606) 263-6500.

 

Big Sandy Health Care is now providing Behavioral Health services for students in schools. These services include assessments to determine the need for counseling and the provision of counseling to students. By signing and dating this document, I am authorizing and consenting for my child to have an assessment performed by a Big Sandy Health Care-employed Therapist or Counselor. I further authorize Big Sandy Health Care’s Therapist or Counselor to meet with my child during the school day to provide Behavioral Health counseling services.

I understand that Big Sandy Health Care must follow all laws on patient privacy and confidentiality. Each state has exceptions to laws on privacy and confidentiality when the safety and wellbeing of a person is in question. Under such exceptions, reports to a third party are required. Big Sandy Health Care Therapists and Counselors are required by law to make a report to a third party for safety reasons when they are presented with statements and other surrounding circumstances that involve any of the following: the abuse of a minor child; the abuse of a senior citizen or dependent adult; a patient who has threatened the safety, wellbeing or life of another person; and a patient who has threatened to harm himself/herself or take his/her own life. If a professional has reasonable cause to believe that a victim with whom he or she has had a professional interaction has experienced domestic or dating violence and abuse, the professional shall provide the victim with educational materials related to domestic or dating violence and abuse including information about how he or she may access regional domestic violence programs or rape crisis centers and information about how to access protective orders. Upon the request of a victim, a professional shall report an act of domestic or dating violence and abuse to law enforcement, after first discussing the making of such report with the victim.

I hereby authorize and consent for my child to receive Behavioral Health services at his/her school from a Big Sandy Health Care employed-Therapist or Counselor. I further authorize and consent for my child’s Big Sandy Health Care Therapist or Counselor to share information about my child, on a need-to-know basis, with school personnel. I understand that I can terminate Behavioral Health services and revoke this consent, in writing, at any time. I understand that if I want Big Sandy Health Care to provide treatment information about my child to anyone other than school personnel, I will have to authorize and consent, in writing, to release information.

I give my permission for Big Sandy Health Care Inc., through its Therapists and Counselors, to provide Behavioral Health services to my child, who is listed above.