Wind River Family and Community Healthcare Form

### Wind River Family and Community Healthcare #### S.T.A.R.S (Students That Are Receiving Services) Program \ *CONSENT OF PARENT OR LEGAL GUARDIAN OR OTHER PERSON WHO HAS PRIMARY RESPONSIBILITY FOR THE CARE OF THE CHILD* \ \ According to law, parents or legal guardians must provide consent for their child to participate in preventative screenings and treatment provided by Wind River Family and Community Healthcare Center for all American Indian/Alaskan Native children who qualify under PL 93-638 and choose to participate at.

Locations
512.511.N. 12th E Street
Riverton, WY 82501

14 Great Plains Road
Arapahoe, WY 82510

707 Blue Sky HWY 132
Ethete, WY 82520

Wind River Family and Community Healthcare Center may utilize healthcare professionals in training, working under the supervision of licensed WRFCHC or other healthcare professionals under contract with WRFCHC to administer dental, optometry, well-child, behavioral, all telehealth, and public health services. I understand that telemedicine/telebehavioral health is the use of electronic information and communication by a healthcare provider to deliver services to an individual when he/she is located at a different site than the provider, and hereby consent to WRFCHC providing telehealthcare services to patients via telemedicine. All WRFCHC healthcare professionals are subject to federally-mandated background checks and determination of suitability pursuant to the WRFCHC Child Background and Character Investigation Policy and Procedure. Parent/guardian or legal caregiver will receive an information sheet of rendered services containing assessment and examination results with the listed recommendations as to continuing needs and/or treatment referrals. Contact information for providers, and follow-up instructions for care and treatment including what to do in case of a need for urgent or emergency response.