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.
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.