Consent to Treat By Signing this Consent for Health Services, I agree to the terms and conditions regarding Authorization to Release Information and Assignment of Insurance Benefits as explained on Page Two of this Consent. I also acknowledge that I have received information about how to receive Notice of Privacy Practices as explained in this Consent. I also have received and understand available services as described in the frequently asked questions which accompanied this Consent.
I voluntarily give my consent for my child identified above to receive telehealth services through Family Medical Associates. I authorize any FMA physician or advanced practice provider to provide such care. I understand that this consent will remain valid through the 2023-2024 academic year unless revoked by me. I may revoke this consent for treatment at any time by requesting in writing that the District remove my child from services. I understand that additional verbal consent will be attempted by the school nurse to be obtained prior to each appointment except in the event my child is emancipated or able to consent for treatment without consent of a parent or legal guardians as permitted in applicable Texas law. I understand that I will be notified of any services my child receives except in the event my child is emancipated or able to consent for treatment without the consent of a parent or legal guardian as permitted in applicable Texas law. I also understand that I should contact the school nurse if I have questions regarding any necessary follow up care or instructions. It is my responsibility to notify the school nurse of all updates or changes to my child’s health conditions or insurance coverage.