KAP Telemedicine Minor Consent

Please correct the errors described below.

Authorization for Treatment - THIS IS FOR EXISTING PATIENTS ONLY

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 Telemedicine service is not a evisit, teleheath, two-way communication, virtual room or video provided.
  • I understand that my insurance carrier does not cover this service and will not reimburse KAP and the service will be paid at time of service with a cc.
  • I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
  • I understand that the telemedicine 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 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 telemedicine 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 telemedicine services.
  • I understand that this document will become a part the patients’ 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 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 telemed 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.
If selecting option 2 or 3 please names below:

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 telemedicine visits shared with me in a language I understand.

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

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