Parental Consent Form

Consent to Treatment
I am the parent, legal guardian or legal custodian of, or otherwise have legal authority to consent to medical treatment for, the minor child named above (the “Student”), who is a student of the school named above (the “School”). I have notified the School of my relationship to the Student or other legal authority and provided any requested documentation of the same. I give my permission to the health care providers of TELESCOPE HEALTH, and such assistants and other health care providers as they may deem necessary, to provide medical services to the Student if and when I and/or the staff of the School determine that a telemedicine consultation with TELESCOPE HEALTH is necessary or desirable. I understand that I am consenting to one or more telehealth visit(s) in which health care providers will ask me, the Student, School staff, and/or other caregivers of the Student questions about the Student’s medical history and current symptoms and/or use remote technology to collect limited health care data. I acknowledge that there are both benefits (such as obtaining care quickly and efficiently) and limitations (such as the provider’s inability to address emergency situations or to collect and/or verify certain data) of seeking care by telemedicine instead of in person. I understand by signing this form, I am authorizing TELESCOPE HEALTH to treat the Student for as long as I and/or the School staff seek care for the Student from TELESCOPE HEALTH providers, or until I withdraw this consent in writing.

Photo Consent
I authorize TELESCOPE HEALTH to capture a photographic image of the Student, and to keep and use such photographic image solely for patient identification purposes.

Statement of Financial Responsibility/Assignment of Benefits
In consideration of TELESCOPE HEALTH advancing credit to me for the health care and services authorized by this consent, I hereby irrevocably assign and transfer to TELESCOPE HEALTH all benefits and payments now due and payable or to become due and payable to me and/or for the benefit of the Student under any insurance policy or policies, under any replacement policies thereof, under any self-insurance program, under any third-party actions against any other person or entity, or under any other benefit plan or program for this or any other period of care.

I understand and acknowledge that this assignment does not relieve me of financial responsibility for all TELESCOPE HEALTH charges incurred on behalf of the Student, and I hereby accept such responsibility, including but not limited to payment of those fees and charges not directly reimbursed to TELESCOPE HEALTH by any benefit plan or program. Furthermore, I agree to pay all costs of collection, reasonable attorneys’ fees and court costs incurred in enforcing this payment obligation.

Authorization to Process Claims & Release of Information
I authorize TELESCOPE HEALTH, on behalf of its independent contractor physicians, non-physician practitioners and/or professional corporations that render services to the Student, to process claims for payment by my and/or the Student’s insurance carrier(s) on behalf of me and/or the Student for covered services provided to the Student by such providers. I authorize the release of necessary information, including medical information, regarding medical services rendered during any consultation and treatment or any related services or claim, to such insurance carrier(s), including any managed care plan or other payor; my past and/or present employer(s); Medicare; CHAMPUS/TRICARE; authorized private review entities and/or utilization review entitles acting on behalf of such insurance carrier(s), payors, managed care plans and/or employer(s); the billing agents and collection agents or attorneys of TELESCOPE HEALTH and/or its independent contractor physicians, non-physician practitioners, and/or professional corporations; and, as applicable, the Social Security Administration, the Health Care Financing Administration, the Peer Review Organization acting on behalf of the federal government and/or any other federal or state agency for the purpose(s) of satisfying charges billed and/or facilitating utilization review and/or otherwise complying with the obligations of state or federal law. Authorization is hereby granted to release the Student’s protected health information (as defined in the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)), including the Student’s health record data and/or copies thereof, to the Student’s primary care, attending and/or admitting healthcare professional and/or any consulting healthcare professional and/or any healthcare professional to whom the Student may be referred for follow up care. I authorize TELESCOPE HEALTH to disclose certain minimal necessary information about me (including name, address and telephone number) to a health system or primary care provider network for the purpose of referring the Student to a primary care provider, to the extent that the Student does not already have one; provided that such disclosure will not result in any remuneration to TELESCOPE HEALTH. I authorize TELESCOPE HEALTH to disclose the Student’s protected health information (including a care summary and recommendations for further treatment) to the School to ensure continuity of care. I further authorize TELESCOPE HEALTH and any healthcare provider or professional rendering medical services to the Student as an independent contractor of TELESCOPE HEALTH to obtain from any source the Student’s protected health information, including medical history, examinations, diagnoses, and treatments, and other health or insurance authorization information for the purpose(s) of satisfying charges billed and/or facilitating utilization review, providing medical treatment and/or the evaluation of such treatment, and/or otherwise complying with the obligations of state or federal law. I understand that information disclosed pursuant to this authorization may be subject to further disclosure by the recipient and may no longer be protected by HIPAA. I understand that this authorization for the use and disclosure of the Student’s protected health information does not have an expiration date and shall be valid until I revise or revoke this authorization.  I understand that I may revoke this authorization by giving written notice at any time to TELESCOPE HEALTH, except to the extent that action has been taken in reliance on this authorization. I understand that I may refuse to make this authorization and TELESCOPE HEALTH may not condition treatment on whether I make this authorization. A photocopy of this Authorization shall be considered as valid as an original.

Medicare Patient Certification, Authorization to Release Information, Application
If the Student is a Medicare beneficiary, I certify that the information provided by me when requesting payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about the Student to release to the Social Security Administration or its intermediaries or carriers any information necessary for this or a related Medicare claim. I request that payment of authorized benefits be made on behalf of the Student.

 

By signing below, I acknowledge that I have read and agree to this consent and authorization form.  I represent that I am the personal representative of the Student for HIPAA purposes, that I have described my relationship to or authority to act on behalf of the Student below, and that I have the authority to consent to treatment and sign authorizations for the use and disclosure of protected health information on behalf of the Student.