Health Care Provider Authorization And Parent/guardian Consent Form (Page 3 of 3) in pdf

Health Care Provider Authorization

My signature below provides authorization for the above written orders. I understand that all procedures will be

implemented in accordance with state laws and regulations. I understand that unlicensed designated school

personnel under the training and supervision provided by the school nurse may perform specialized physical health

care services. This authorization is valid for the duration of the current school year. If changes are indicated in the

meantime, I will provide new written authorization.

Authorized Health Care Provider’s Name: _____________________________________ Phone: ___________

Provider’s Address: ___________________________________________________________________________

Signature: ____________________________________________________________

Date: _______________

NPI#___________________________________________ Approved Ohio ORP: YES/NO

Parent/Guardian Authorization

My signature below acknowledges that I have reviewed and agree to the health care provider’s orders as outlined in

this document. I understand that unlicensed designated school personnel under the training and supervision

provided by the school nurse may perform specialized health care services. I understand that I am responsible for

providing all supplies and equipment necessary for the care of my child at school. I understand that our health care

provider must authorize any potential changes to my child’s plan of care in writing.

I hereby give my permission for the above named student to receive and consume the medication(s) as directed in

this document. I assume responsibility for the safe delivery of medication to school. I agree to notify the school

immediately if there is any change in the medication order(s) and understand that school personnel may confirm

such change(s) with my child’s health care provider via telephone, fax or in writing. I understand that it is my

child’s responsibility to come to the office to receive the medication. I understand that no person authorized by the

Board of Education to administer medication will be liable for administering or failing to administer unless such

person acts in a manner constituting negligence or wanton/reckless misconduct.

Signature of Parent/Guardian: _______________________________ Relationship to Student: _____________

Date: ______________ Home Phone: ____________ Work Phone: _______________ Cell: ______________

Health Care Provider Authorization And Parent/guardian Consent Form Page 3