• I give my consent for Ballad Health Medical Associates, its physician(s) and other healthcare providers (providers) to examine (student’s name) and to provide care and treatment, which may include the evaluation, diagnosis, consultation and treatment of my child’s medical condition using advanced telecommunications technology (telemedicine services.)

• I understand that if my child requires telemedicine services, reasonable attempts will be made to contact me and invite me to join the medical visit by phone or video technology. If I cannot be reached in a timely manner, I understand and give consent for my child to be seen by providers in my absence and to provide me with a summary of the visit upon my request.

• I understand that telemedicine services may include audio, video or other electronic media and providers may:
(1) be located off-site;
(2) examine my child face-to-face via telemedicine technology and/or review health information transmitted via telemedicine technology; and
(3) rely on information provided by my child and/or other on-site healthcare professionals.

• I understand and agree that providers shall not be held liable for factors beyond their control (such as technology failures, incomplete or inaccurate data provided by others, or distortions of images due to electronic transmission.) I understand that reasonable steps will be taken to protect the confidentiality of patient data, but the security of electronic information cannot be guaranteed.

• I understand that other individuals may be present during the visit to operate telemedicine equipment and technology, and I consent and authorize audio/video recording or photography to be taken in order to provide the telemedicine services to my child. These recordings or photographs may become part of my child’s medical record.

• I understand that if a provider believes that further healthcare services are required or would benefit my child, a referral or recommendation for follow-up care may be made.

I have read this form or had it read to me, and I understand its contents. By signing below, I affirm that:
(1) I agree to all of the statements above, and
(2) I authorize telemedicine services to be provided to my child during the current school year

• I authorize and grant to Ballad Health Medical Associates permission to bill my insurance company or other applicable third-party payor(s) for healthcare services provided to my child. I also authorize direct payment from my insurance company to Ballad Health Medical Associates for the healthcare services provided to my child.

• I assign and convey directly to Ballad Health Medical Associates my rights under the applicable insurance and/or benefit policies, so that Ballad Health Medical Associates may obtain payment for healthcare services provided to my child. I assign to Ballad Health Medical Associates: (1) the right to claim payment for goods and services provided to my child by Ballad Health Medical Associates; (2) the right to any settlements or legal remedies; and (3) the option (but not the obligation) to appeal or pursue any denied or delayed claims.

• I authorize Ballad Health Medical Associates to release information – which relates to the healthcare services provided to my child – to my insurance company, applicable third-party payor(s), and/or their representatives. I also authorize my insurance plan and other applicable third-party payor(s) to release information to Ballad Health Medical Associates regarding benefits, coverage and settlement information.

• I understand and agree that I am fully responsible for any unpaid bills not covered by my insurance policy, including co-payments, deductibles, and/or other out-of-pocket costs, in accordance with Ballad Health Medical Associates’ fee schedule. If I do not have insurance coverage, I understand that I will be billed directly for Ballad Health Medical Associates’ services to my child. I agree to promptly pay any such out-of-pocket amounts for the healthcare services provided by Ballad Health Medical Associates to my child.

I have read this form or had it read to me, and I understand its contents. By signing below, I affirm that I understand, acknowledge and agree to all of the statements above.

This practice is an affiliate of Ballad Health. Ballad Health is committed to honoring those we serve by delivering the best possible care. Consistent with the Ballad Health-wide mission and shared values of our employed physicians, our physician employees agree to refer their patients to providers, practitioners and suppliers within the Ballad Health system whenever their patients need medical services not available at this practice and whenever such referral is in the individual patient’s best interest, not contrary to the patient’s express choice and not inconsistent with the requirements of the patient’s insurance.

I certify that the information given by me in applying for payment under the Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration, or its intermediaries or carriers, any information needed for this or a related Medicare/Medicaid claim. I further certify that I have provided any required information concerning any other liability for medical practice charges in order to complete the Medicare Secondary Payor (MSP) form. I request that payment of authorized benefits be made on my behalf. I authorize Ballad Health Medical Associates to secure information from the Department of Human Services regarding my qualification for Medicaid.