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School Telehealth Consent Form_OC

Patient's Name(Required)

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Daytime Phone Number(Required)

Preferred Pharmacy(Required)

School the Patient Attends (if a Student)(Required)

Throop Elementary

Paoli Jr.-Sr. High School

Orleans Elementary

Orleans High School

Springs Valley Elementary

Springs Valley High

Patient's Grade (if a student)(Required)

Preschool

Kindergarten

Staff

Other

Verbal Consent for Each Visit

In addition to written consent, for any patient under the age of 18, a parent/guardian will be contacted before each visit to receive verbal consent. If the verbal consent cannot be provided due to inability to answer phone, phone number disconnected, etc. please indicate if the patient can or cannot be seen by a provider at the Telehealth Clinic. Please initial the appropriate line below regarding verbal consent.

Permission to be seen(Required)

I give permission for the patient to be seen at the Telehealth Clinic if parent/guardian cannot be reached and verbal consent is not received. “See my child even if you cannot reach me.” Choice

I give permission for the patient to be seen at the Telehealth Clinic only if verbal consent from parent/guardian is received for each appointment. I understand that if parent/guardian cannot be reached, the patient will not be seen at the Telehealth Clinic. “I want to speak with the school nurse before my child is seen.”

Choose only one option

Sharing Records with Primary Care Provider (PCP)

Telehealth Clinic providers will provide a copy of the visit's medical record, including lab results, medications prescribed, assessment and plan of treatment for any patient that has an established primary care provider outside SICHC. Sharing of medical information with the PCP requires the consent of the patient or patient’s parent/guardian.

Sharing records with Primary Care Provider (PCP)(Required)

I consent to sharing medical information to patient’s PCP when seen at the Telehealth Clinic.

I DO NOT consent to sharing medical information to patient’s PCP when seen at the Telehealth Clinic.e

Choose only one option

Primary Care Physician Consent - Contact Information

If you consented to share medical information with the patient's PCP (from above), please provide their contact information:

Primary Care Physician Consent - Contact Information

Physicians Name

Phone

Address

Labs

Southern Indiana Community Health Care, Inc. may order in-house laboratory tests (strep, flu, etc.) to determine the appropriate diagnosis and treatment plan. Please initial if the provider can order in-house labs for the patient.

Untitled

I consent to ordering in-house labs.

I DO NOT consent to order in-house labs.

Insurance

As the patient or parent/guardian of the patient, I:

Insurance(Required)

Authorize the release of any information necessary to process insurance claims for payment of benefits to Southern Indiana Community Health Care, Inc.

Authorize payment of benefits to Southern Indiana Community Health Care, Inc. for services rendered.

Have provided details of all insurance policies that cover the patient.

Please check all statements you agree to

Consent

I have had the opportunity to read this form in its entirety and understand the information provided. All my questions have been answered to my satisfaction. The information on the proceeding pages is true and complete to the best of my knowledge.

Consent Name(Required)

My name typed into the answer space to this statement serves as my electronic signature.

Date(Required)

MM slash DD slash YYYY

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Name

First Last

Date

MM slash DD slash YYYY

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School Telehealth Consent Form_OC

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