Receive health care services available from and deemed necessary by the staff of the Warrior Wellness Center and their associated provider agencies. These services may include, but are not limited to, such procedures as evaluation and treatment of acute illness and injuries either in person at the clinic or via telehealth services provided through their school nurse’s office. Consent is also given for referral of care and if needed, emergency transportation to other physicians, health care professionals, hospitals, clinics, or health care agencies as deemed necessary by the clinic and its staff. Consent is also given for telehealth services, if necessary, and for a WCSD school nurse to remain in the examiner room during telehealth services. Consent is further given for the school nurse to share with clinic staff any protected health information or any other medical information maintained by the school nurse as an education record under the Family Education Rights and Privacy Act (FERPA) with clinic staff.
By signing this form, I also authorize Wilkinson County School District (WCSD) to release my child’s medical information to Community Health Care Systems, Inc for the purpose of best serving my child medically through the services listed above. Medical Information will include allergies, current medications, current medical conditions, insurance/Medicaid information, and parent contact information (phone numbers, address, email).
The Warrior Wellness Center School-Based Health Clinic encourages each student to involve his/her parent or guardian in health decisions whenever possible. Consent for services is authorized for the current school year and will require annual renewal.
I have read and understand the above information and I give permission for my child’s care as described. I also understand that I may obtain further information regarding the health services offered by the clinic by contacting the clinic at (478) 946-1030.