Student Name: / Sex: Male Female
Social Security Number:
______- _____- ______ / District/School: / Grade: / Date of Birth:
_____/_____/_____
Mother/Guardian: ______
Home #: ______Work #:______Cell #: ______
Home Address: ______
______
City State Zip Code / Father/ Guardian: ______
Home #: ______Work Phone:______Cell #: ______
Home Address: ______
______
City State Zip Code
Emergency Contact: ______
Name Relationship to Child Phone Number
Does your child have medical problems or receive medical treatment for medical problems? ¨ Yes ¨ No
If yes, please explain:
Does your child take any medicine everyday? ¨ Yes ¨ No
If yes, please explain:
Has your child had surgery or been hospitalized? ¨ Yes ¨ No
If yes, please explain:
Has your child ever had any of the following medical problems? Check ALL that apply.
Asthma / Fainting spells / Orthopedic problems (bone or joint)
Low iron in blood / Heart Problems (murmur) / Sickle Cell Disease (not trait)
Cancer / Hemophilia (bleeding problems) / Tuberculosis
Diabetes / Lead poisoning (lead in the blood) / Urinary problems (kidney or bladder)
Epilepsy/Seizures / Meningitis / Hernia
Bone/muscle problems
(pain, trouble walking) / Neurological Problems
(brain or spinal cord) / Other (explain):
Is your child allergic to any of the following? Check ALL that apply and list what your child is allergic to and the type of reaction they have:
Food(s): / Requires Epi Pen: ¨ Yes ¨ No
Medicine(s): / Requires Epi Pen: ¨ Yes ¨ No
Bee or other insect(s): / Requires Epi Pen: ¨ Yes ¨ No
Does your child have any of the following problems? Check all answers that apply.
Frequent headaches / Hernia / Frequent illnesses
Dental problems (toothache, cavities) / Gross motor (clumsy, poor balance) / Skin problems
Frequent ear infections / Vision problems (wears glasses) / Bed wetting
Learning problems / Shortness of breath / Other (explain):
Emotional/Behavior Problems / Hearing problems
If yes, to any of the above, please explain:
What is your child’s Doctor’s Name? / Date of last visit & why?
What is your child’s Dentist’s Name? / Date of last visit & why?
What is your main source of payment for medical care? ¨ Medicaid ¨ Other Insurance ¨ None
If Medicaid, please indicate Medicaid Number: ______
PERMISSION FOR SERVICES
I give permission for my child to receive medical treatment as deemed necessary by the school nurse. Medication may only be given at school only when the relevant policies and rules for Assisting Students with Medications are followed. In the case of emergency and I cannot be reached, I would like for my child to be transported to the nearest emergency room by Emergency Medical Services (EMS).
Marion County School Districts and the State Department of Education have my permission to provide health-related services to my child and to release and exchange medical and other confidential information, as necessary, to the Department of Health and Human Services, the Department of Health and Environmental Control, and any third party insurance carrier regarding health-related services provided to my child prior to the date of this consent or thereafter for services that the school district/agency will provide in the future.
By signing this form, I give the School District my permission to bill Medicaid and any third party insurance and receive payment from Medicaid or any third party insurer for health-related services as set forth in my child’s individualized education program (IEP), and for psychological evaluation services, nursing services, and other health-related treatment services billable to Medicaid without the requirement of an IEP.
I understand that Medicaid reimbursement for health-related services provided by the School District will not affect any other Medicaid services for which my child is eligible. I understand that if my child has an IEP, my child will receive the services listed in the IEP regardless of whether I enroll my child in public or private benefits or insurance programs. I also understand that my refusal to allow public access to the Department of Health and Human Services or any third party insurance carrier does not relieve the District of its responsibility to ensure that all required services are provided at no cost to me. I understand that the granting of consent is voluntary on my part and may be revoked at anytime. If I later revoke my consent, that revocation is not retroactive (i.e., it does not negate an action that has occurred after the consent was given and before the consent was revoked).I also understand that the School District will operate under the guidelines of the Family Educational and Privacy Act to ensure confidentiality regarding my child’s treatment and provision of health related services.
I request the School District release and receive information in regards to my child’s health to the medical professionals listed above.
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Parent/Guardian Signature Date