KAP Telehealth Over 18yr 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 understand that I 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 telemedicine 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 my records may be shared with other individuals for scheduling/billing purposes only.
  • I understand that my insurance carrier may request access to the patients 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 “KAP credit card vault form"
  • I understand that KAP may charge my vaulted credit card for partial or all services that the insurance carrier might not cover.

Update Primary Insurance

Update Primary Insurance

Update Secondary Insurance (Optional)

Update Secondary Insurance

    Please upload a file

    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.

    This will be used for contact purposes only
    Will be on file and used for communication

    Your message will be encrypted and can only be read by Kid Approved Pediatrics.