School Telehealth Consent Form

Before anyone is seen at the School-Based Telehealth Clinic (“Telehealth Clinic”), this consent form must signed and on file and proper documentation of insurance obtained. I, the undersigned,

    • Give permission and consent for the patient to be seen by a licensed health care provider through and by the Telehealth Clinic. I consent to the encounter and understand that the healthcare provider will do their best to provide reasonable medical advice and treatment based on the patient’s telehealth visit.
    • Have received a description of services and understand the nature of the treatment provided at the Telehealth Clinic, the way it is provided, and that there are limitations of this form and style of treatment.
    • Understand that this consent form is valid for one school year at the school the patient is enrolled in at the time of registration and I may revoke the consent at any time by providing notice to the school nurse.
    • Understand that this consent constitutes the establishment of a provider-patient relationship between the patient and any provider employed by Southern Indiana Community Health Care, Inc. who examines the patient through the Telehealth Clinic for encounters at the school the student is enrolled in at time of registration, and that I may revoke this consent at any time by providing notice to the school nurse.
    • Give permission for Southern Indiana Community Health Care to receive information from the school about the patient’s health history including medical history, allergies, and medications.
    • Acknowledge that the school nurse and nurse assistants are employees of the school listed above and will be participating and assisting in the treatment of the student.
    • Give permission for the SICHC Telehealth provider, the school nurse, nurse assistants, and the patient’s primary health care provider to speak with and share medical information about the patient’s health issue on an as needed basis, with the understanding that this information will be treated in a confidential way.
    • Understand that Southern Indiana Community Health Care, Inc. will document each encounter with the patient in a medical record maintained by SICHC and not at the school listed above.
    • Acknowledge that I have been offered a copy of the Southern Indiana Community Health Care, Inc. HIPAA compliance Patient Consent Form, which addresses the ways in which Southern Indiana Community Health Care, Inc. maintains, uses, and discloses the patient’s protected health information.
    • Understand that I will receive a visit summary from the school nurse or nurse assistants for the patient’s encounter, either in writing or over the phone, which will include diagnosis, treatment options, any need to seek additional care, instructions for follow-up care, and any prescriptions issued.


School Telehealth Consent Form

MM slash DD slash YYYY
School the Patient Attends (if a student)(Required)
Patient's Grade (if a student)(Required)

Verbal Consent for Each Visit

In addition to written consent, for any patient under the age of 18, a parent/guardian will be contacted before each visit to receive verbal consent. If the verbal consent cannot be provided due to inability to answer phone, phone number disconnected, etc. please indicate if the patient can or cannot be seen by a provider at the Telehealth Clinic. Please initial the appropriate line below regarding verbal consent.

Permission to be seen(Required)
Choose only one option

Sharing Records with Primary Care Provider (PCP)

Telehealth Clinic providers will provide a copy of the visit's medical record, including lab results, medications prescribed, assessment and plan of treatment for any patient that has an established primary care provider outside SICHC. Sharing of medical information with the PCP requires the consent of the patient or patient’s parent/guardian.

Sharing records with Primary Care Provider (PCP)(Required)
Choose only one option

Primary Care Physician Consent - Contact Information

If you consented to share medical information with the patient's PCP (from above), please provide their contact information:

Please enter the provider's name, address, and phone number.


Southern Indiana Community Health Care, Inc. may order in-house laboratory tests (strep, flu, etc.) to determine the appropriate diagnosis and treatment plan. Please initial if the provider can order in-house labs for the patient.



As the patient or parent/guardian of the patient, I:

Please check all statements you agree to


I have had the opportunity to read this form in its entirety and understand the information provided. All my questions have been answered to my satisfaction. The information on the proceeding pages is true and complete to the best of my knowledge.

My name typed into the answer space to this statement serves as my electronic signature. (Name and Date)

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