Student Emergency Information Form - The School District Of Greenville County
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1250-180 rev 2013
Teacher: ____________
Student Emergency Information Form
Student’s Name: _______________________________
Grade: ____
Birth Date:________________
Home Address: ________________________________________________________________________________
Please indicate any health conditions that require treatments, procedures, medications, or health monitoring for your student during the school
day. Please list the physician treating your child as well:
___________________________________________________________________________________________________________
--------------------------------------------------------------------------------------------------------------
Mother/Guardian: _____________________
: ___________
: ___________
: ___________
Work Phone
Cell Phone
Home Phone
Father/Guardian: _____________________
: ___________
: ___________
: ___________
Work Phone
Cell Phone
Home Phone
Emergency Contacts: Please list two contacts that will be called ONLY if you cannot be reached in an emergency.
Name: __________________________ Relationship: ___________________ Phone: ____________________________
Name: __________________________ Relationship: ___________________ Phone: ____________________________
The principal and/or school nurse may share health information with individuals who have responsibilities for my child. I authorize District
officials to contact the person named on this form and authorize the named physician to render to my child whatever emergency treatment
deemed necessary. If the physician, other persons named above, or parent cannot be reached, the District Officials may take whatever action
they deem necessary for the health of my child. I will not hold The School District of Greenville County responsible for the emergency care
and/or transportation of my child. I will keep the school informed of any changes on this form.
Signature of Parent/Guardian
Date
:
:
--------------------------------------------------------------------------------------------------------------
Consent for Treatment, Release of Information, and Medicaid Reimbursement
The school District of Greenville County (the District) requests your permission to bill and receive payment from Medicaid
for services as permitted under Part B of the individuals with Disabilities Education Act (IDEA), and as set forth in your
child’s Individualized Education Program (IEP). The District may also bill Medicaid for psychological evaluation services,
nursing services, and other health-related services billable to Medicaid without the requirements of an IEP.
This consent also allows the District and State Department of Education to release and exchange medical, psychological,
and other personal identifiable confidential information, as necessary, to the Department of Health and Human Services
regarding services provided to your child.
Notification of Use of Public Benefits (Medicaid)
Prior to this request for consent, you received
. A signed consent for
release of information to bill Medicaid is a one-time consent and is not required annually. The District will, however,
provide you annual written notification of your rights before Medicaid accesses your child’s benefits to pay for services
under the IDEA. The District will operate under the guidelines of Part B of the IDEA and the Family Educational Rights
and Privacy Act (FERPA) to ensure confidentiality regarding your child’s treatment and provision of services.
Medicaid reimbursement for services provided by the District will not affect any other Medicaid services for which your
child is eligible. Granting consent is voluntary on your part and may be revoked at any time. Granting or denying
consent for Medicaid billing does not impact any district-provided services for your child.
Your signature below authorizes the District to seek reimbursement from Medicaid for services included in your child’s
In addition, non-IEP services including psychological evaluations,
Individualized Education Program (IEP).
nursing services, and other health-related services may be billed for reimbursement.
_______________________________________________________ _________________________________________
Student’s Name
/
Date
Student’s Date of Birth
____________________________________________________________________ ____________________________________________________
Student’s Medicaid Number
Signature of Parent/Guardian
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