KAP Telehealth Minor Consent

Please correct the errors described below.

Authorization for Treatment

Telemedicine services at Kid Approved Pediatrics 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 understand that KAP Telehealth visit is an e-visit, two-way video communication, virtual room or video solution.
  • I understand that the same standard of care applies to a telehealth visit as applies to an in-person visit.
  • I understand that the telehealth appointment applies to only one patient/family member unless multiple appointments are scheduled for each patient/family member.
  • I understand the appointment is set for 15 min, however, it could be less/more time depending on diagnosis. If it is determined another appointment or follow up is necessary, your provider will inform you.
  • I am giving consent for a Non-Guardian to be present with the patient during the telemedicine appointment and have the authority to make medical decision on behalf of the legal guardian.
  • I understand that the patient will not be physically in the office/room with the provider.
  • I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
  • If it is determined the equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit via email or patient portal.
  • I understand that I have the right to refuse to participate or decide to stop participating in a telehealth visit, and that my refusal will be documented in the patient's file. I also understand that my refusal will not affect my right to future care or treatment.
  • I may revoke the right to use telehealth at any time by contacting KAP at 972-787-0044.
  • I understand that the laws that protect privacy and the confidentiality of health care information apply to telehealth services.
  • I understand that this document will become a part of my medical record.
  • I understand that the patient records may be shared with other individuals for scheduling/billing purposes only.
  • I understand that my insurance carrier may request access my medical records for quality review/audit.
  • I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telehealth visit via “credit card vault authorization”.
  • I understand that KAP may charge my vaulted credit card for partial or all services that the insurance carrier might not cover.

Patient Info

Additional Child

Parent/Guardian Info

Must Be Different From Father
Must Be Different From Mother
Must Be Different From Father
Must Be Different From Mother

Update Primary Insurance

Additional Insurance

Update Secondary Insurance (Optional)

Additional Insurance

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