KAP Credit Card Vault Authorization

Please correct the errors described below.

CC Vault Authorization

Kid Approved Pediatrics Telemedicine services is leveraging one or more of the following ways of communicating with patients and/or guardians: HIPPA Compliant Voice System, HIPPA Compliant Email or HIPPA Compliant Patient Portal. These solutions/options will enable the providers to deliver health care services to patients when located any-where in the Texas region.

  • I have read, signed and submitted a KAP Telemedicine Consent prior to or along with the cc vault authorization.
  • I understand that KAP telemedicine service is not an e-visit, teleheath, two-way video communication, virtual room or video solution.
  • I understand that my insurance carrier does not cover this service and will not reimburse KAP and the service will be paid at time of service with a cc.
  • I understand that my telemedicine visit is flat fee of $70.00.
  • I understand that the telemedicine payment applies to only one patient/family member. If there are multiple appointments for additional patients/family members I will be charged for each patient/family member..
  • I understand that ONLY ONE telemedicine visit will be scheduled within 5 days per patient/family member.
  • I understand that my cc will be vaulted securely in a HIPPA compliant cc system for current/future telemed services.
  • I understand that should my cc on vault fails, KAP will require another form of payment. If secondary payment is un-successful by means of contact or not able to process payment, KAP may choose to remove patient from the telemed option and will be required to come into the office treatment.
  • I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in the patient's file. Should this occur, KAP may still submit to the insurance carrier for the time spent. I also understand that my refusal will not affect my right to future care or treatment.
  • I understand should I resume telemed service, I might be required to resubmit a new credit card vault consent form.
  • I understand this document will become a part the patients’ medical record.
  • I understand a no show or if guardian can’t be reached at the time of the telemed appointment or within 5 min a $25 charge will be applied to my credit card.
  • I may revoke the right to have my credit card vaulted by contacting KAP in writing either by mail or email: staff@kidapprovedpediatrics.net.
  • I understand that should I need to cancel my telemed appoint, I need to contact KAP 24hr in advanced or a $25 charge will be applied to my credit card.
  • I understand a SAME DAY telemed appointment is canceled a $25 charge will be applied to my credit card.
  • I authorize KAP to vault my credit card in our HIPPA compliant cc system.
  • I authorize KAP to charge my cc for the telemed consult/visit.
  • I authorize KAP to charge my cc should I occur a fee should any of the above situations occur.

Billing Address

This will be used for contact purposes only
This will be used for contact purposes and receipts only

Credit Card Vault

Must be 16 num
Must be 3 num
Please make sure email provided is correct above

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine cc vaulting in a language I understand.

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