Informed Consent for Healthcare

Thank you for choosing Healthy Campus, Campus Physicians of California, P.C. and/or Rume Medical Group, Inc. for you or your child’s medical and behavioral health school-based services. Our mission is to increase the health of patients by providing access on School Campuses. This program is designed to benefit you and your children by providing medical and behavioral health services to you and/or your child in a high quality, time efficient, and cost-effective manner.

Section I. Introduction

Healthy Campus offers school-based wellness programs that provides access to a wide range of services including wellness screenings, medical diagnostics, healthcare treatment, and behavioral health services to individual students and groups onsite at school as well as via telehealth.

Healthy Campus works with Campus Physicians of California, P.C. and Rume Medical Group, Inc., professional medical groups that maintain a network of employed and contracted licensed clinical health care providers, including but not limited to licensed pediatricians, nurse practitioners, physician’s assistants, nurses, and behavioral health therapists  (hereinafter “Provider”).

Once I consent, Provider will evaluate you and/or your child and make recommendations for services.  We will keep you informed of the services you and/or your child receives in a manner consistent with all laws, rules, and regulations.

As care is provided, parents and guardians are welcome to be involved in their children’s care, and to contact Campus Physicians of California, P.C. or Rume Medical Group if they have any questions or suggestions.

Section II. Telehealth Definition:

Services maybe provided via telehealth.  Telehealth involves the delivery of health and wellness services using electronic communications, information technology, or other means between a licensed, certified, or registered healthcare professional at one location and a patient in another location about a clinical matter. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education. Telehealth services may involve various modalities, including asynchronous interactions, real-time video and audio encounters and interactive audio with store and forward.

Section III. Benefits of Telehealth:

It can be easier and more efficient for you and your child to access health and wellness services. You can obtain health and wellness services at times that are convenient for you without the necessity of an in-office appointment, including follow-up care related to your treatment. If you need follow-up care, please contact us through our website www.healthycampus.com and we will help make arrangements for you to see a Provider.

Section IV. Risks of Telehealth

Information transmitted to your health professional may not be sufficient to allow for appropriate health or wellness services to meet your particular need. Some clinical needs may not be appropriate for a telehealth visit. The technology necessary to interact with health professionals may fail and delay service.

Section V. Not for Emergencies

Telehealth services are not to be used in a medical or psychiatric emergency. In an emergency please dial 911 or go to the nearest emergency room.

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Authorization for Wellness Program:

I am the parent or legal guardian of the patient. I authorize Campus Physicians of California, P.C. or Rume Medical Group, Inc, a professional medical corporation (“Provider”) to conduct a wellness program for me and/or my child.  If required by my insurance provider, I designate Campus Physicians of California, P.C. or Rume Medical Group, Inc. as my primary care provider for this service. I understand that the wellness program may include but is not limited to the following services:

• Mental Health Screening and follow up care
• Vision
• Hearing
• Physical Exam
• Height/Weight
• Heart Rate
• Listen to heart/lungs
• Musculoskeletal (hop on one foot)
• Check eyes/ears/mouth
• Review medical history
• Immunizations

I hereby authorize and consent to the provision of medical care deemed necessary by Provider, and its agents, associates or assistants, which Provider deems necessary as part of the wellness program while I and/or my child is attending school in the current District (hereinafter the “Treatment”).  This authorization shall be effective beginning today and ending at the end of 2038.

Other Provisions: 

I understand that, by signing, I am authorizing Provider to receive and disclose to other persons, including but not limited to school representatives and public health authorities the outcome of my or my child’s wellness screening (including tests from third party sources). I understand that federal and state laws afford these records greater privacy. In disclosing this information, I understand that Provider will take reasonable measures to limit disclosures of this information to the extent reasonably possible, but I recognize that circumstances may require identifying my or my child as an individual exposed to or  infected with COVID-19, or related health conditions in order to properly warn others so they may take precautionary measures.

I authorize Provider to disclose medical information obtained pursuant to this authorization so that Provider can get paid for the Treatment.

I understand that I am making an assignment of my insurance benefits, covering myself and my dependents, to Provider and/or its authorized agents.  I further understand that Provider may bill my insurance and that in accordance with the unless permitted by law, Provider shall not balance bill for the wellness screening services.

Informed Consent for Telehealth Services

Introduction

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care.  Providers may include primary care practitioners, specialists, and/or subspecialists.  The information may be used for examination, treatment, diagnosis, and/or follow-up, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files
• Electronic systems used incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

• Improved access to medical care by enabling a patient to remain in his or her home, physician’s office or at a remote site while the physician obtains test results and consults from healthcare practitioners at distant sites.
• More efficient medical evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telehealth.  These risks include, but may not be limited to:

• Information transmitted may not be sufficient (g., poor resolution of images) to allow for appropriate medical decision making by the physician and/or other healthcare providers.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• Security protocols could fail, causing a breach of privacy of personal medical information.

By signing, I understand and consent to the following:

1. I understand that the electronic nature of the telehealth services means that there is a greater risk to the privacy of my or my child’s health information.
2. In some cases, my or my child’s Provider may be a nurse practitioner or physician assistant and not a physician.
3. Persons may be present during the telehealth visit other than my or my child’s Provider in order to operate the telehealth technologies and/or for language translation assistance, if requested. If another person is present during the telehealth visit, the school/student will be informed of the individual’s presence and his/her role.
4. I understand that information pertaining to my or my child that is provided as part of any telehealth offering will be treated as accurate, true, and complete. I understand that I may have opportunities to correct any incorrect information.
5. I understand that in certain instances, and in compliance with applicable law, my or my child’s Provider may determine that it is appropriate to provide my or my child’s medical treatment asynchronously via store-and-forward technology. In such instances, my or my child’s Provider and my or my child may communicate electronically through the Electronic Platforms and not via telephone or video.
6. I understand that by using the Electronic Platform I may not always be speaking or messaging with my or my child’s provider in real-time, and there may be a delay before my messages or information is reviewed. I understand that I must check the Electronic Platform for messages because this is the way that my or my child’s Provider will communicate important information to me.
7. I understand that there is no guarantee that my or my child will be provided medication and that the decision of whether a prescription is appropriate will be made in the professional judgment of my or my child’s Provider. I understand that while the use of telehealth may provide benefits to my or my child, no such benefits or specific results can be guaranteed, and my condition may not improve.
8. I understand there is a risk of technical failure during the telehealth encounter beyond the control of Campus Physicians of California, P.C. or Rume Medical Group, Inc. and my or my child’s Provider(s).
9. I understand the following:

• The laws that protect the privacy and confidentiality of medical information also apply to telehealth.
• I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
• I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.
• A variety of alternative methods of medical care may be available to my child, and I may choose one or more of these at any time. My or my child’s provider has explained the alternatives to my satisfaction.

10. I have a right to receive a copy of this consent form.

Parental Consent To The Use of Telehealth for my and / or my Child’s Treatment

I am the parent or legal guardian of the patient.  I have read and understand the information provided above regarding telehealth, I have discussed it with my or my child’s provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction.  I hereby give my informed consent for the use of telehealth in the delivery of medical care to my or my child.

I hereby authorize Campus Physicians of California, P.C. or Rume Medical Group, Inc. (name of provider) to use telehealth in the course of  treatment for myself and/or my child.

 

Immunization Release

I consent to the administration of the vaccine(s) by a medical professional employed by a Healthcare Provider (HCP) appointed by Healthy Campus for myself and/or my child. I consent to be contacted at the number provided above regarding other immunizations for which I and/or my child(ren) are due or eligible to receive. I also release Healthy Campus, HCP, its affiliates, officers, directors, employees, and agents from all liability, including acts of omission or commission, resulting or arising from my receipt of this vaccination. I understand that: 1) I have voluntarily chosen to receive the vaccination and understand that I am obligated to pay for all products and services received, if applicable. 2) I may be responsible for payment after the date of service if the product or service is billed to my medical benefit. 3) I am of legal age and authorized to execute this consent form or I am the parent/guardian of the minor patient. 4) I will immediately alert the HCP of any medical conditions which may adversely affect my personal health or effectiveness of the vaccine. 5) I have been counseled about potential side effects after vaccination, when they may occur, and when and where I should seek treatment. I am responsible for following up with my physician at my expense if I experience any side effects. 6) I should remain in the area for 15 minutes after the vaccination for observation. 7) I have read, or have had read to me, the Vaccine Information Statement(s) (“VIS”) or Emergency Use Authorization (“EUA”) provided for the vaccine(s) to be administered. I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction. I understand the benefits and risks of the vaccine(s). 8) I have been offered and/or provided a copy of the HCP’s Notice of Privacy Practices in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 9) This vaccination, including any vaccination granted additional privacy protections under state or federal law, is subject to reporting by my pharmacy or its business associate to an immunization registry, which may share my immunization data with others, and to my primary care physician, the authorizing physician, or the local Department of Health, if applicable, and I authorize these disclosures.

I certify that I have read the foregoing and was provided the opportunity to ask questions, and agree and accept all of the terms above.