Morgan County School System

Telemedicine Enrollment Form
Certified Nurse Practitioner available to see your child at school this upcoming school year

Dear Parent/Guardian,

In partnership with Morgan County Schools, Morgan County Medical Center (MCMC) will provide a limited range of medical services for our students, faculty and staff through an off-site MCMC Nurse Practitioner via a Telemedicine Station. MCMC can provide medical services for your child similar to a regular office visit, accepting most insurance types for the medical services provided. The goal of this program is to provide immediate access to medical care similar to that of an urgent care clinic. This program is not intended to replace your primary physician and should be considered a supplemental medical care service. If your child does not have a primary care physician, MCMC can provide primary care services in their office.

Here’s how the medical service will work for children enrolled in the service:
When the school nurse identifies an illness that requires medical attention, the nurse will notify the parent/guardian and offer the option of arranging an in-person visit, or telemedicine visit with the Nurse Practitioner. The parent or guardian understands that the school nurse will be present to assist with the visit.

Prior to medical evaluation, the school nurse will make reasonable attempts to notify the student’s parent/guardian with the contact information on file. If the school nurse is unable to make contact and the appropriate forms are on file, the school nurse will determine whether to proceed with treatment based upon your child’s symptoms and medical complaints.

As the parent/legal guardian of the student, you give permission for your child to utilize this program by:
• Signing the registration form to authorize your child’s participation;
• Copy of front and back of insurance card;
• Returning the registration form and this completed form to the school nurse.

We’re confident you and your child will greatly enjoy the experience and compassionate care of a Board Certified Family Nurse Practitioner (FNP-BC). They will provide excellent care for both our students/faculty and will work closely with each school nurse to provide medical services, via a mobile telemedicine station that is established in each school-based clinic.

It is important to note several key points:
• Only the students enrolled in the school based clinic and telemedicine program will be eligible to receive school-based
treatment. Parents/guardians must complete and return the appropriate enrollment form that is being sent home and
update insurance information as needed.
• Prior to a clinical or telemedicine medical evaluation, the school nurse will make reasonable attempts to notify the
student’s parent/guardian with the information they have on file. If the school nurse is unable to make contact, and the appropriate forms are on file, the school nurse will determine whether to proceed with treatment based upon the child’s symptoms and medical complaints.

If you have any questions regarding this program or need assistance completing this form, please contact your child’s school nurse.