KAP Telehealth Minor Consent

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

Parent/Guardian Info

Update Primary Insurance

Update Secondary Insurance (Optional)

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 telehealth visits shared with me in a language I understand.