Cumberland Family Medical Center, Inc.
School Based Health Centers – CONSENT FORM
SCHOOL DISTRICT: __________________
SCHOOL:_____________________
Please read carefully, COMPLETE FORM, SIGN, and DATE. Student should return this form to their homeroom teacher.
Consent will not expire until the Center is notified in writing that you wish to revoke such.
I give my consent for:
Social Security
Number
to receive any of the following services at Cumberland Family Medical Center, Inc. School Based Health Centers:
Student’s Full Name
Birth Date
1. Physical assessment of acute or chronic illness; assessment of growth and development;
2. Treatment of minor health problems as defined by protocol, including administration of over-the-counter medications
such as acetaminophen and decongestants;
3. Basic laboratory test (when needed to assess problem) such as finger stick for anemia and blood sugar, urine test
for bladder or kidney infection, and strep screen for sore throat;
4. Health education and promotion;
5. Dental examination, cleaning, and home care instruction; dental sealants and x-rays, as needed;
6. Mental health counseling, as needed;
7. Referrals to outside agencies for services that may not be provided at the School Based Health Center;
8. Physical exams; Sports/School/Well Child
9. Immunizations/Influenza vaccine
10. Visual and hearing screenings; and,
11. Other services
.
YOU WILL RECEIVE NOTIFICATION PRIOR TO ANY SERVICE PROVIDED TO YOUR CHILD.
I give consent:
Initial
1. To Cumberland Family Medical Center, Inc. School Based Health Center (hereinafter CFMC SBHC) staff to
review my child’s school record, including attendance and other information, if applicable, that will assist the staff
in helping my child;
2. To have my child participate in on-going evaluations of the Center program, including questionnaires and surveys;
3. For CFMC SBHC staff to disclose to appropriate school staff medical information as CFMC SBHC staff deem
necessary;
4. For the following hospitals to release to CFMC SBHC the emergency room reports on my child: Russell Co.
Hospital, Westlake Regional Hospital, Clinton Co. Hospital, Cumberland Co. Hospital, Wayne Co. Hospital, Casey
Co. Hospital and Lake Cumberland Regional Hospital;
5. For CFMC SBHC to disclose to any appropriate agencies or medical practitioner any medical and billing
information that may result through my child’s contact with the Center;
6. For the CFMC SBHC staff to obtain any records or information from any agency or private professional regarding
my child’s care. CFMC SBHC is released from all liability that may arise from the release of such information; and,
I do agree that the completed information is true to the best of my knowledge. I understand that Cumberland Family
Medical Center, Inc. shall provide a copy of their Notice of Privacy Practices upon my request, which is also available at
www.cumberlandfamilymedical.com. I request payment of authorized medical insurance benefits be made to Cumberland
Family Medical Center, Inc. on my child’s behalf for services he/she received; I realize I am responsible to pay for any
non-covered services and/or services requiring insurance authorization, my child receives. I also authorize Cumberland
Family Medical Center, Inc. to release medical information about my child to their insurance company (Medicare, KCHIP,
Medicaid, and other third-party payers) to determine payment for services.
I do give my consent for all services listed above. I do certify that I am of full capacity to execute the above authorization
and release.
Date
Signature of Parent/Legal Guardian
Relationship to Patient