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5330 F1/page 1 of 3AUTHORIZATION FOR MEDICATION OR TREATMENT (PHYSICIAN/NURSE PRACTITIONER STATEMENT)To the Parent/Guardian or Adult Student:THE FOLLOWING INFORMATION IS NECESSARY FOR ANY STUDENT
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Gather all necessary personal information, including name, address, and contact details.
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Determine the specific health services you require and any relevant medical history.
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Fill out the application form accurately, ensuring all sections are completed.
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Provide any required documentation, such as identification or insurance information.
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Submit the application through the designated channel, whether online or in person.

Who needs health services in non-sacc?

01
Individuals seeking preventive care or wellness checks.
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People with chronic conditions requiring regular monitoring and treatment.
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Those needing immediate care for illnesses or injuries.
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Families looking for vaccinations or health education resources.
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Anyone who is uninsured or underinsured and requires access to basic health services.
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Health services in non-SACC refers to healthcare services that are provided outside the scope of the Statewide Automated Child Welfare Information System (SACC). It encompasses a range of medical, mental health, and social services delivered to individuals.
Organizations and agencies that provide health services outside the SACC framework are required to file health services in non-SACC, including healthcare providers, clinics, and mental health facilities.
To fill out health services in non-SACC, providers must complete a designated form that includes patient information, types of services rendered, dates of service, and any relevant billing codes. Ensure all information is accurate and submitted according to guidelines.
The purpose of health services in non-SACC is to ensure that individuals receive appropriate healthcare support and that these services are tracked and reported for funding and compliance purposes.
Reporting must include patient demographics, service types, dates of service, billing information, and outcomes of the services provided.
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