Ritchie Regional Health Center Telehealth Kiosk Consent Forms

RRHC Telehealth Kiosk Consent Forms

Student's Information

Student's Full Name:*

Student's Preferred Name (if different from above):

Date of Birth:*

Date

Sex:*

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number:*

Please enter a valid phone number.

Social Security #:

School:*

Grade:*

Parents/Legal Guardian (please list all working numbers)

Father's Name:

Date of Birth:

Date

Home Phone:

Cell Phone:

Other Phone:

Mother's Name:

Date of Birth:

Date

Home Phone:

Cell Phone:

Other Phone:

Guardian's Name:

Date of Birth:

Date

Home Phone:

Cell Phone:

Other Phone:

Student lives with:

Parent/Guardian Email:

example@example.com

Communication Preference:

Phone CallTextEmail

Would you like to enroll at RRHC's Patient Portal? If you select yes, an invite will be sent to the email you listed above.

Yes, please.No, thanks.I'm already enrolled but would like to add the student to my account.

EMERGENCY CONTACT(S) and Sharing of Protected Health Information (PHI)

Please list anyone other than yourself, that has permission to bring the student to be seen AND indicate if we have permission to share the student's medical results with. You do NOT need to list medical providers or other medical institutions.

Emergency Contact 1 Name:

Emergency Contact 1 Relationship to Student:

Emergency Contact 1 Home Phone:

Emergency Contact 1 Cell Phone:

Emergency Contact 1 Other Phone:

Do we have permission to share the student's medical results with this individual:

YesNo

Emergency Contact 2 Name:

Emergency Contact 2 Relationship to Student:

Emergency Contact 2 Home Phone:

Emergency Contact 2 Cell Phone:

Emergency Contact 2 Other Phone:

Do we have permission to share student's medical results with this individual:

YesNo

Health Insurance Information

Student Insurance Status:*

Student IS insuredStudent is NOT insured

Primary Insurance

Primary Insurance Company Name:*

Policy/ID Number:*

Primary Insurance Company Zip Code:

Insured's Name:

Insured's Date of Birth:

Date

Insured's SS#:

Secondary Insurance

Secondary Insurance Company Name:

Policy/ID Number:

Secondary Insurance Company Zip Code:

Insured's Name:

Insured's Date of Birth:

Date

Insured's SS#:

No Health Insurance

Ritchie Regional Health Center is a nonprofit organization that receives federal funds, which enables us to offer the Sliding Fee Scale Program. The Program provides discounted rates for services based on family size and income level. If the student is uninsured or underinsured, please contact us to request a Sliding Fee Scale application.

Guarantor Information (who is responsible for the bill e.g. copay)

*Please fill out regardless of insurance status. Do NOT list insurance company's information here.

Guarantor's Name:*

Guarantor's Date of Birth:

Date

Guarantor's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Guarantor's Primary Phone:*

Please enter a valid phone number.

Guarantor's Alternative Phone:

Please enter a valid phone number.

Guarantor's Relationship to Student:*

Student's Health Information

Student's Primary Care Provider:

Student's Dentist:

Student's Preferred Pharmacy:

Student's Preferred Pharmacy Address:

Has student ever had allergic reactions to bee stings:

YesNo

If yes, does the student have a prescription for an EpiPen:

YesNo

Does the student have any known food allergies:

YesNo

If yes, please list:

Has the student ever had an allergic reaction to medication:

YesNo

If yes, please list AND describe the reaction:

Please list any current medications, the dosage (mg), and instructions. Be sure to include vitamins or supplements:

Student's Current/Past Medical History

Please check all medical conditions that apply, indicating if they are current or past:

	Current	Past
ADD/ADHD
Asthma
Birth Defects
Bladder Problems
Constipation
Diabetes
Diarrhea
Drug/Alcohol
Ear Infections
Epilepsy/Seizures
Hearing Problems
Heart Problems
Kidney Disease
Mental Illness/Depression
Mononucleosis
Pneumonia
Rheumatic Fever
Scoliosis
Sinus Problems
Speech Problems
Stomach Problems
Thyroid Disease
Urinary Disease

Please list any other current/past medical condition not listed above:

Does the student have a disability?

YesNo

If yes, please describe the disability:

Student's Race, Ethnicity, Housing Status, and Language

Race (check all that apply):

Ethnicity:

Not Hispanic/LatinoHispanic/Latino

Housing Status:

Not HomelessHomeless ShelterPublic Housing

Language:

EnglishSpanishOther

Ritchie Regional Health Center is a nonprofit organization that receives federal funds, which enables the health centers to provide services to our patients at discounted rates based on family size and income level through the Sliding Fee Program. Please help us ensure that funding is continued by completing the information below. We appreciate your cooperation.

Annual Income:*

Number of Household Members:*

Telehealth Informed Consent

Telehealth services involve the use of secure interactive videoconferencing equipment (Let’s Talk Interactive) that enable health care providers to deliver health care services to patients when located at different sites.

1.) I understand that the same standard of care applies to a telehealth visit as applies to an in-person visit.

2.) I understand that my child will not be physically in the same room as my provider. I will be notified of and my consent obtained for anyone other than the provider present in the room.

3.) I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
- If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that the provider may discontinue the visit and make other arrangements to complete the visit.

4.) I understand that I have the right to refuse my child’s participation or decide to stop participating in a telemedicine visit and that my refusal will be documented in my child’s medical record. I also understand that my refusal will not affect my child’s right to future care or treatment.

5.) I understand that the laws that protect privacy and the confidentiality of health care information apply to telehealth services.

6.) I understand that my child’s health care information may be shared with other individuals for scheduling and billing purposes.
- I understand that my insurance carrier will have access to my child’s medical records for quality review/audit.
- I understand that the guarantor will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my child’s telehealth visit.
- I understand that health plan payment policies for telehealth visits may be different from policies for in-person visits.

7.) I understand that this document will become part of my child’s medical record

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 alternative to telehealth visits shared with me in a language I understand; and (3) am located in the state of West Virginia and will be in West Virginia during my telehealth visit(s).

Please initial if you consent for the student to use telehealth services:*

Texting Consent

1.) RRHC offers patients, parents or guardians the opportunity to communicate by text messaging. Text messaging is not to be used to convey medical information or to discuss medical conditions. Text message communication has a number of possible risks that patients, parents or guardians should consider before using text messaging. If the patient, parent or guardian is worried about any information being seen by other people, or if the question or problem is urgent, other form(s) of communication such as telephone or portal communication should be used. Some of the possible risks of using text messaging include, but are not limited to, the following:
- Text messages can be sent on to other people, stored on a computer, or printed out on paper for storage. b. Text message senders can easily misaddress their message. c. Text message information is easier to change than handwritten or signed documents. d. Text message information may be kept on computers/electronic devices even after the sender or the recipient believes they deleted his or her copy. e. Employers and on-line services have a right to archive (store) and look at text messages transmitted through their systems. Some, but not all, employers store text messages indefinitely. f. Text messages can occasionally be intercepted, changed, forwarded, or used without authorization or detection. g. Text messages can be used as evidence in court.

2.) The health care providers will use reasonable means to protect the security and confidentiality of text message information sent and received. However, because of the risks outlined above, the health care providers cannot guarantee the security and confidentiality (privacy) of text messaging communication, and will not be liable for improper use and/or disclosure of confidential information (including Protected Health Information that is the subject of the federal Health Insurance Portability and Accountability Act of 1996). Thus, the patient, parent or guardian must consent to the use of text for patient information.

I acknowledge that I have read and fully understand the information the health care provider/Practice has provided me regarding the Risks of using text messaging. I understand the Risks associated with the communication of text messages between the health care provider/Practice and me, and consent to the Conditions outlined. In addition, I agree to the above instructions, as well as any other instructions that the health care provider/Practice may impose regarding text message communications.

Please initial if you acknowledge and understand RRHC's texting policy:*

Parent/Legal Guardian Consent

I understand that in case of an emergency, every effort will be made by the health center staff to notify me. The health center will attempt to call me when the student/my child presents themselves to the health center. If they are unable to contact anyone, a note will be sent home with the student/my child. I authorize that the student's/my child's photo can be taken for identity/security purposes for their electronic medical records. I authorize the release of verbal or written information pertinent to the student's/my child's healthcare between the school nurse and the health center staff only when necessary for his/her care. I authorize a physician, physician's assistant, family nurse practitioner, behavioral health professional, or other health professionals to provide necessary and/or advisable treatment. I agree for a healthcare student to be present. I am aware that the Notice of Privacy Practice is posted at the health center. I authorize the health center to release information regarding treatment to third-party payers such as Medicaid or insurance for the purposes of billing and for any reason in accordance with acceptable medical practice pursuant to the law. I assign my insurance benefits to be paid directly to the health center. I am financially responsible for non-covered services but understand that services will not be denied due to inability to pay.

Patient Signature or Parent/Guardian Signature:*

Clear

Date*

Date