I give permission for my child/self to obtain routine health services at the School-Based Health Center.
All insurances will be billed at time of visit. No out-of-pocket costs for medical services rendered in school. No one will be refused services due to the inability to pay. Well-child screening visits may be completed for healthy lifestyle assessment, for students with asthma, and for students who receive behavioral health services.
RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION
I authorize the release of any medical or behavioral health information necessary to process my claim. I also authorize payment of health benefits to Child & Family Agency for services provided.
CONSENT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES
I understand and acknowledge that I have read and understand this consent and I have received CFA’s Notice of Privacy Practices currently in effect. I understand that information regarding how CFA will use and disclose my information can be found in CFA’s Notice of Privacy Practices. I understand my consent is effective for as long as CFA maintains my protected health information.
AUTHORIZATION FOR EXCHANGE OF HEALTH AND EDUCATION INFORMATION
I give permission to allow Child & Family Agency (CFA) to exchange as needed information with my child’s medical provider, school nurse, and key school personnel in order to effectively care for my child.