Bradley County Schools – Cleveland City Schools Telemedicine Form

Bradley County Schools - Cleveland City Schools Telemedicine Form

Please click the link for more information - Telemedicine Parent Information Sheet

Demographic Information:

School System(Required)

County Schools(Required)

City Schools(Required)

Patient's First Name(Required)

Patient's Middle(Required)

Patient's Last Name(Required)

Patient's Social(Required)

Patient's Birthdate(Required)

Male

Female

Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Cell Number(Required)

Email Address(Required)

Insurance Information:

Primary Insurance(Required)

Name of Insured(Required)

Insurance ID#1(Required)

Group #1(Required)

DOB of Insured (Primary)(Required)

Secondary Insurance

Name of Insured

Insurance ID#2

Group #2

DOB of Insured (Secondary)

Medical History:

Allergies:(Required)

Medications:(Required)

Surgeries:(Required)

Special Health Needs:(Required)

Preferred Pharmacy(Required)

Pharmacy Phone(Required)

HIPAA-ACKNOWLEDGEMENT AND CONSENT TO TREAT

Notice of Privacy Practices and Consent for Ocoee Pediatrics Telemedicine Services

Patient's Name(Required)

Patient's DOB(Required)

We at Ocoee Pediatrics are required by law to maintain the privacy of and provide individuals with the attached Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with our office manager in person or by phone at our main phone number. If you would like a copy of the Notice, please ask your child’s school nurse.

Check each line if you agree to the following:

Check Box3(Required)

I understand that if the patient is experiencing a medical emergency, the patient’s school will be directed to dial 9-1-1 immediately and that our providers are not able to connect me directly to any local emergency services.

Check Box4(Required)

I understand that alternatives to telemedicine consultation, such as in-person services with my primary care physician are available and offered to me prior to telemedicine services, and in choosing to participate in a telemedicine consultation, I understand that some parts of these services involving tests (e.g., strep, flu, covid, urine) may be conducted by the school system, at the direction of our providers.

Check Box6(Required)

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that federal and state law requires health care providers to protect the privacy and the security.I understand that Ocoee Pediatrics will take steps to make sure my health information is not seen by anyone who should not see it.

Check Box7

I understand that if the patient is covered under a state medicaid plan (Bluecare/Amerigroup), Ocoee Pediatrics will request a PCP change during the visit. I understand that this does not change the primary care physician establishment. This is solely for billing purposes. I schedule with my established pediatrician/primary care physician for follow up appointments and routine care.

I have carefully read this form and fully understand its contents, including the risks and benefits of the telemedicine services. I acknowledge that I understand and agree with the above and hereby consent to receive care through Ocoee Pediatrics telemedicine services. I understand that telemedicine services rendered by Ocoee Pediatrics does not take place of my established primary care physician and that I need to continue any routine health care needs with my pediatrician/Primary care physician. I hereby acknowledge that I have received the HIPAA Notice of Privacy Practice document.

Signature(Required)

Printed Name(Required)

Parent Signature Date(Required)