Fillable Patient Consent Form

Child’s Name

Parent/Guardian Name

School

Teacher

Grade

Dear Parent(s)/Legal Guardian(s),

Congratulations! Your child’s school will participate in the Kids’-Doc-On-Wheels (KDOW) School-Based Health Care Telehealth Clinic for the 2018-2019 school year. KDOW will provide medical services for students through an onsite medical team (i.e. school nurse, staff assistant, and virtual provider) with the iCare Counter, a telehealth station. The goal is to provide on-site access to medical care and services similar to that of a pediatric office. KDOW accepts all Medicaid and most private insurance plans. This program is not intended to replace your primary physician but can be considered an additional service. If your child does not have a primary care physician (a medical provider your child sees regularly), KDOW can become your child’s Primary Care Provider (PCP)!

Please select ONE program option for your child.

Full KDOW Program

KDOW will become your child’s PCP
Primarily seen on the unit with Telehealth as a supplement
Access to mobile Behavioral Health Services, mobile Dental Services, and Telehealth Services

Behavioral Health Services provided by Licensed Behavior Specialist through KDOW
Dental Services provided by Help-A-Child-Smile

We provide all services done in a traditional Pediatrician’s Office

Well Exams (Child Health & Development Interactive System (CHADIS) questionnaire required for ages 0-5 & 11-18 years old)

CHADIS is a web-based screening, diagnostic and management system that administers and analyzes child pre-visit. CHADIS improves the diagnosis and management of health, developmental and behavioral issues, helping Clinicians address parents' concerns about their child's health and development. CHADIS questionnaire can be completed online at https://www.site.chadis.com/

Sick Visits
Sports Physicals
Vaccines
Flu Shots and more

During School breaks our unit will be located at convenient locations in your local community. There is also availability after school hours. For after school hour access, please call 404-574-2512

My Child’s School Based Health Care Telehealth Clinic

If the school nurse identifies a student that requires medical attention, the parent/guardian will be offered the option of a telehealth visit.
Primarily seen by a provider virtually with the mobile unit as a supplement
Per Georgia law, patients seen via Telehealth only must have an in person visit on the mobile unit once a year.

Services Provided through Telehealth are as follows:

Chronic Illness Management

Allergy
Asthma
ADHD
Elevated BMI/ Obesity

***In order for child to receive Telehealth services while in school, a consent form has to be on file!***

As the parent/legal guardian of a student, you give permission for your child to utilize the program by:

Signing the registration form to authorize child’s participation
Providing Copy of front and back of insurance card
Returning the consent form back to the school nurse or other designated school personnel

We’re confident you and your child will greatly enjoy the experience and compassionate care of KDOW. If you have any questions please contact KDOW at contact@kidsdoconwheels.org or 404-574-2512

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

WHAT TYPE OF MEDICAL INSURANCE DO YOU CURRENTLY HAVE?
PLEASE PROVIDE PROOF OF INSURANCE OR MEDICAID YOU MAY BE HELD FINANCIALLY RESPONSIBLE FOR SERVICES RENDERED. PLEASE LIST ALL INSURANCE COVERAGE THE CHILD IS ELIGIBLE FOR.

Name of Policy Holder/Guarantor

Date of Birth

Relationship to Patient

Name of Insurance /Medicaid

ID/Policy #

Group #

Secondary Insurance Name

Policy #

Group #

Not Insure (Please check if applicable)

CONSENT/REFUSAL FORM FOR THE USE OF TELEHEALTH

PURPOSE: The purpose of this form is to enroll your child into the Kids’-Doc-On-Wheels, Inc. (KDOW) telemedicine program in connection with the following procedure(s) and/or services: Medical Services, Dental Services, and Behavioral Health Services.

1. NATURE OF TELEHEALTH CONSULT: During the telemedicine consultation:

Details of your child’s medical history, examinations, x-rays, and tests will be discussed with our healthcare professionals through the use of interactive video, audio, and telecommunication technology.
A clothed physical examination of your child may take place.
A non-medical technician may be present in the telemedicine studio to aid in the video transmission.
Video, audio, and/or photo recordings may be taken of your child during the procedure(s) or service(s).
Parent(s)/Legal guardian(s) will have the option of being present for the evaluation in person by phone or via link (www.kidsdoconwheels.org; www.emdanywhere.com) that is sent from the telemedicine system to allow them to participate using a desktop or smartphone. If you are unable to participate, you will receive timely follow-up communication from a KDOW representative regarding the child’s medical evaluation and treatment.

2. MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to your child’s medical information and medical records, apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.

3. CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telemedicine consultation.

4. RIGHTS: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your child’s right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

5. DISPUTES: You agree that any dispute arriving from the telemedicine consult will be resolved in Georgia, and that Georgia law shall apply to all disputes.

6. RISKS, CONSEQUENCES, & BENEFITS: You have been advised of all the potential risks, consequences, and benefits of telemedicine. Your child’s healthcare practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation during regularly scheduled school meetings. All your questions have been answered, and you understand the written information provided above.

I agree to participate in my child’s School Based Health Care Telehealth Clinic.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

If signed by someone other than the patient, indicate relationship

I refuse to participate in my child’s School Based Health Care Telehealth Clinic.

Signature

If signed by someone other than the patient, indicate relationship

Witness

Date

Time

Patient Information

Child’s Full Name (First, Middle, Last)

Date of Birth

If mixed race / Please specify

Address

Apt. #

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email address

Primary Language

Does your child receive special services?

Yes No

If yes, please explain

Consent to receive texts

Yes No

Emergency Contact Name

Relationship to Patient

Phone Number

GENERAL HISTORY

Does the patient have any allergies to medications, food and /or anything else?

Add new row

Please List Daily Medication Names and Dosages:

Add additional Medications

Pharmacy Name

Reactions

Any Health Problems Under Treatment?

Yes No

If yes, explain

Where treatment was received?

Has your child seen a doctor in the last year?

Yes No

If yes, how many times?

1 time 2 times 3 times 4 or more times

Where?

Why?

Has your child used a Hospital Emergency Room in the last year?

Yes No

If yes, how many times? (Please Check)

1 time 2 times 3 times 4 or more times

Where?

Why?

Was your child in the hospital overnight in the last year?

Yes No

Where?

Why?

How Long?

Is your child up to date on their immunizations?

Yes No Unsure

Has your child’s hearing and vision been screened recently?

Yes No

If so, when?

Family History

Medical problems / Reason for death (if deceased)

Add Additional History

ILLNESS HISTORY

If other, Please specify

Menstruation Started (at what age?)

When was your child’s last dental visit?

Does your child have dental problems?

Yes No

Has your child had a toothache recently

Yes No

Has your child had a recent injury to the teeth or jaws

Yes No

Does your child have a finger or thumb sucking habit?

Yes No

BEHAVIORAL HEALTH QUESTIONAIRE

Does your child have behavior issues at home or school?

Yes No

Does your child seem to be hyper and require constant redirection?

Yes No

Does your child have a hard time with school or homework?

Yes No

Does your child seem sad often?

Yes No

Has your child ever threatened/or tried to harm him/her self or others?

Yes No

Is your child constantly involved in conflict with peers or authority figures?

Yes No

Is there anything else you would like us to know concerning your child’s health?

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Your information will be encrypted.

Fillable Patient Consent Form

**Please select ONE program option for your child.**

CONSENT/REFUSAL FORM FOR THE USE OF TELEHEALTH

Patient Information

GENERAL HISTORY

Family History

ILLNESS HISTORY

BEHAVIORAL HEALTH QUESTIONAIRE

Kids Doc on Wheels!

Please select ONE program option for your child.