{"id":6421,"date":"2023-08-10T14:49:28","date_gmt":"2023-08-10T19:49:28","guid":{"rendered":"\/\/www.abcchristmas.com\/?page_id=6421"},"modified":"2023-08-31T10:47:49","modified_gmt":"2023-08-31T15:47:49","slug":"school-based-telehealth-consent-form","status":"publish","type":"page","link":"\/\/www.abcchristmas.com\/school-based-telehealth-consent-form\/","title":{"rendered":"School-Based Telehealth Consent Form"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:0px;--awb-margin-top:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><p>Introduction:<\/p>\n<p>The Colorado Independent School District partners with jogos de halloween
 District (MCHD) and Family Medical Associates (FMA) to offer School-Based Telehealth Services. These telehealth services do not take the place of your regular doctor and participating in this program does not mean you are changing your child&#8217;s doctor. You are encouraged to have any needed follow-up care with the Primary Care Physician.<\/p>\n<\/div><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-6424\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;\" data-form-id=\"6424\" data-config=\"{&quot;form_id&quot;:&quot;6424&quot;,&quot;form_post_id&quot;:&quot;6424&quot;,&quot;post_id&quot;:6421,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;Student_Name&quot;:&quot;Student Name:&quot;,&quot;question&quot;:&quot;Student Date of Birth&quot;,&quot;student_grade&quot;:&quot;Student Grade&quot;,&quot;parentguardian_phone_number&quot;:&quot;Parent\\\/Guardian Name&quot;,&quot;parentguardian_name&quot;:&quot;Parent\\\/Guardian Phone Number&quot;,&quot;students_school&quot;:&quot;Student&#039;s School&quot;,&quot;parentguardian_email_address&quot;:&quot;Parent\\\/Guardian Email Address&quot;,&quot;students_primary_care_provider&quot;:&quot;Student&#039;s Primary Care Provider&quot;},&quot;field_logics&quot;:{&quot;Student_Name&quot;:&quot;&quot;,&quot;question&quot;:&quot;&quot;,&quot;student_grade&quot;:&quot;&quot;,&quot;parentguardian_phone_number&quot;:&quot;&quot;,&quot;parentguardian_name&quot;:&quot;&quot;,&quot;students_school&quot;:&quot;&quot;,&quot;parentguardian_email_address&quot;:&quot;&quot;,&quot;students_primary_care_provider&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;Student_Name&quot;:&quot;text&quot;,&quot;question&quot;:&quot;text&quot;,&quot;student_grade&quot;:&quot;text&quot;,&quot;parentguardian_phone_number&quot;:&quot;text&quot;,&quot;parentguardian_name&quot;:&quot;text&quot;,&quot;students_school&quot;:&quot;text&quot;,&quot;parentguardian_email_address&quot;:&quot;text&quot;,&quot;students_primary_care_provider&quot;:&quot;text&quot;,&quot;submit_1&quot;:&quot;submit&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;}\"><form action=\"\/\/www.abcchristmas.com\/school-based-telehealth-consent-form\/\" method=\"post\" class=\"fusion-form fusion-form-6424\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"Student_Name\">Student Name: <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"Student_Name\" id=\"Student_Name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"question\">Student Date of Birth <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"question\" id=\"question\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"student_grade\">Student Grade <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"student_grade\" id=\"student_grade\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"parentguardian_phone_number\">Parent\/Guardian Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"parentguardian_phone_number\" id=\"parentguardian_phone_number\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"parentguardian_name\">Parent\/Guardian Phone Number <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"parentguardian_name\" id=\"parentguardian_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"students_school\">Student&#039;s School <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"students_school\" id=\"students_school\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"parentguardian_email_address\">Parent\/Guardian Email Address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"parentguardian_email_address\" id=\"parentguardian_email_address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div class=\"fusion-form-label-wrapper\"><label for=\"students_primary_care_provider\">Student&#039;s Primary Care Provider <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"students_primary_care_provider\" id=\"students_primary_care_provider\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"6424\"><div ><button type=\"submit\" class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-1 fusion-button-default-span  form-form-submit button-default\" data-form-number=\"6424\" tabindex=\"\"><span class=\"fusion-button-text\">Submit<\/span><\/button><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2\"><p>Consent to Treat By Signing this Consent for Health Services, I agree to the terms and conditions regarding Authorization to Release Information and Assignment of Insurance Benefits as explained on Page Two of this Consent. I also acknowledge that I have received information about how to receive Notice of Privacy Practices as explained in this Consent. I also have received and understand available services as described in the frequently asked questions which accompanied this Consent.<\/p>\n<p>I voluntarily give my consent for my child identified above to receive telehealth services through Family Medical Associates. I authorize any FMA physician or advanced practice provider to provide such care. I understand that this consent will remain valid through the 2023-2024 academic year unless revoked by me.<b> I may revoke this consent for treatment at any time by requesting in writing that the District remove my child from services.<\/b> I understand that additional verbal consent will be attempted by the school nurse to be obtained prior to each appointment except in the event my child is emancipated or able to consent for treatment without consent of a parent or legal guardians as permitted in applicable Texas law. I understand that I will be notified of any services my child receives except in the event my child is emancipated or able to consent for treatment without the consent of a parent or legal guardian as permitted in applicable Texas law. I also understand that I should contact the school nurse if I have questions regarding any necessary follow up care or instructions. It is my responsibility to notify the school nurse of all updates or changes to my child&#8217;s health conditions or insurance coverage.<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"_links":{"self":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/6421"}],"collection":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/comments?post=6421"}],"version-history":[{"count":11,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/6421\/revisions"}],"predecessor-version":[{"id":6465,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/6421\/revisions\/6465"}],"wp:attachment":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/media?parent=6421"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}