KAP Telehealth Vault Authorization

Please correct the errors described below.

Credit Card Vault Authorization

Kid Approved Pediatrics Telehealth 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 the "KAP Telehealth Consent" prior to or along with the cc vault authorization.
  • I understand that KAP telehealth service is a two-way video communication, virtual room or e-visit solution.
  • I understand that my insurance carrier may not cover telehealth and may not reimburse KAP to which the service will be charged to my credit card.
  • I understand that the telehealth 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 my cc will be vaulted securely in a HIPPA compliant cc system for current/future telehealth services.
  • I understand that should my cc on vault be declined in anyway, 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 future telehealth appointment and will be required to come into the office for treatment.
  • 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. 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 telehealth 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 telehealth appointment or within 5 min a $25 charge will be applied to my credit card.
  • I may revoke the right to have my cc vaulted by contacting KAP in writing either by mail or email: staff@kidapprovedpediatrics.net.
  • I understand that should I need to cancel my telehealth 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 telehealth appointment is canceled a $25 charge will be applied to my credit card.
  • I authorize KAP to vault my cc utilizing a HIPPA compliant cc system.
  • I authorize KAP to charge my cc for the telehealth 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 Info

Must be 16 numbers
Must be 3 #
    Please upload a file

    By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

    This will be used for contact purposes only

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