I, as parent/guardian, understand that I will not be charged for any of the services provided at the health center. I also understand that the Family Service Center or the medical provider may bill Medicaid or other insurance providers for these services. I authorize/assign payments of authorized benefits directly to the Family Service Center. By signing below, we (student and parent/guardian) acknowledge that we have read and understand the services to be provided at the school-based health center. We both give permission for this student to receive the services provided by the program. This consent is effective while the student is enrolled in West Feliciana Parish School system unless the School-Based Health Center is notified in writing, that I no longer wish for my child to receive services. I understand that I may be asked to complete a one page form every year to update important information. We also understand that the school-based health center is operated by the West Feliciana Parish School System and its employees and contractors. _______________________________________ ______________________________________ Printed Name of Parent/Legal Guardian/Student Relationship _______________________________________ __________________________________ Signature of Parent/Legal Guardian Date ______________________________________ ___________________________________ Signature of Student (optional) Date This consent may be withdrawn or modified at any time with written permission of the parent/guardian and student to the entity referred to above. A duplicate copy of this document will be given to parents or guardians upon request.
I, as parent/guardian, understand that I will not be charged for any of the services provided at the health center. I also understand that the Family Service Center or the medical provider may bill Medicaid or other insurance providers for these services. I authorize/assign payments of authorized benefits directly to the Family Service Center. By signing below, we (student and parent/guardian) acknowledge that we have read and understand the services to be provided at the school-based health center. We both give permission for this student to receive the services provided by the program. This consent is effective while the student is enrolled in West Feliciana Parish School system unless the School-Based Health Center is notified in writing, that I no longer wish for my child to receive services. I understand that I may be asked to complete a one page form every year to update important information. We also understand that the school-based health center is operated by the West Feliciana Parish School System and its employees and contractors. _______________________________________ ______________________________________ Printed Name of Parent/Legal Guardian/Student Relationship _______________________________________ __________________________________ Signature of Parent/Legal Guardian Date ______________________________________ ___________________________________ Signature of Student (optional) Date This consent may be withdrawn or modified at any time with written permission of the parent/guardian and student to the entity referred to above. A duplicate copy of this document will be given to parents or guardians upon request.
SBHC_Consent_Form_2017-2018.docx