Parent/Legal Guardian: To protect the rights and honor the wishes of our patients and their parents/legal guardian(s), Cincinnati Children’s Hospital Medical Center must be aware of the name, relationship and telephone number of the patient’s parent/legal guardian. Except in emergency situations determined by our medical staff or when the patient is legally permitted to consent to his/her own treatment, the patient’s parent/legal guardian must authorize hospitalization and any special procedures. Patients should be discharged only to an appropriate individual pursuant to the Medical Center Policy entitled Persons Authorized to Consent for Admission, Treatment and Discharge of Patients.
CONSENT FOR MEDICAL TREATMENT
For those patients being treated at Cincinnati Children’s Hospital Medical Center (CCHMC), I authorize CCHMC and the doctor(s) participating in the care of my/our child to use any treatment or procedures that may be deemed necessary in the medical or dental care and that may be reasonably expected to be part of the normal inpatient or outpatient service. This shall include the use of drugs, medicines, laboratory procedures, X-ray procedures and diagnostic testing (whether performed at CCHMC or at nearby facilities), immunizations, preventive medicine procedures, routine recreational activities, and the use of local anesthesia during laboratory procedures and diagnostic testing. This consent for treatment does not authorize any type of surgical or medical procedure requiring the use of general anesthesia or sedation. I understand that during the diagnostic or treatment process, the medical team may determine that it is in the best interest of my child to refer him/her to other services within CCHMC. I authorize such transfer and treatment. This authorization shall allow the doctors to provide continuing services until revoked by me in writing. For patients receiving care in the shock/trauma suite, I authorize CCHMC and their physicians to take video/audio recordings of me/my child or part of my/my child’s body while under the care of the hospital. These images can only be used for medical education or performance improvement. Images obtained for either purpose will be destroyed after 180 days. CCHMC may provide certain services utilizing telehealth technology, including transmission of images, video and audio that are encrypted for privacy. The remote provider will determine whether the condition being diagnosed or treated is appropriate for telehealth, and I understand that there is no guarantee of diagnosis, treatment, or prescription for myself/my child. I understand that I/my child may have to travel to see a health provider in-person for certain diagnosis and treatment or in the event of a technical failure.
ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION (FINANCIAL RESPONSIBILITY)
In consideration of services rendered, I authorize payment to Cincinnati Children's Hospital Medical Center for all hospital, physician/professional, and ancillary services rendered, and I assign to CCHMC all right, title, and interest in and to any third party benefits due from any and all insurance policies, employee benefit plans, and/or responsible third party payers in an amount not to exceed CCHMC's regular and customary charges for services rendered. I accept responsibility for determining whether services provided to me are covered by my insurance or other third-party payer, and I understand that I am responsible to CCHMC for charges not covered by my insurance company for services provided. If a referral from my insurance company is required for payment to be made, I assume responsibility for obtaining this referral and for all charges associated with this account if no referral is obtained. I consent to any request for review or appeal by CCHMC to challenge a determination of benefits made by a third-party payer, insurance carrier, or employee benefit plan.
I also authorize CCHMC and any treating physician to release any and all information related to the care and treatment of the patient that may be requested or required by the third party payer (insurance company, government agency or its respective agents, or employer), to the extent necessary to secure payment. I further authorize the release, to the extent necessary, of information from my child's medical record to appointees of the CCHMC medical staff, its allied health professionals, employees and other agents, as well as to accrediting and licensing/regulatory entities who have, in turn, agreed to keep such information confidential, for the purpose of reviewing or auditing the performance of CCHMC, its medical staff, its allied health professionals, its employees and/or agents otherwise assisting CCHMC in the rendering of medical care or the performance of other health care operations. Patient information may be stored electronically and used to improve clinical outcomes. This authorization includes the release of information concerning HIV testing, diagnosis or treatment of AIDS, AIDS-related conditions, drug/alcohol abuse, drug-related conditions, and/or psychiatric/psychological diagnosis and treatment.
NOT FOR EMERGENCY USE: I understand the System is not an emergency response system. If I need emergency care, I will call 911.
I acknowledge and agree that I am participating voluntarily in a CincyKids Health Connect from Cincinnati Children’s offered by my healthcare providers from Cincinnati Children’s and Teladoc Physicians, PA.
I acknowledge that CincyKids Health Connect my reliance upon information obtained is solely at my own risk. Teladoc Health, Inc. and other System third parties shall have no liability for such reliance.
CONSENT TO USE OF MY HEALTH INFORMATION: In connection with my participation in CincyKids Health Connect, I hereby agree and consent to the following:
- The Provider, Teladoc Health, Inc. and other third parties that assist the Provider by providing hardware, software or support components of the System (“System Third Parties”) may use My Health Information to provide the services that are part of the CincyKids Health Connect.
- Teladoc Health, Inc. (“Teladoc”) is a System Third Party that operates the software portions of the System for the Provider and support in connection with the System. Teladoc may collect, collate, manipulate, aggregate, analyze and use My Health Information in a manner that separates from, omits, deletes or otherwise excludes from consideration (and from results or reports) information from which my identity can be readily individually determined.
- I understand and agree that I may access the System using only methods and systems identified to me as enabled or otherwise approved for access.
- If wait time exceeds a prescribed amount of time determined by Cincinnati Children’s then the patient may be seen by another board certified provider and not a Cincinnati Children’s provider.
- I understand and agree that I may receive not only system generated emails related to patient visits, but also from time to time marketing emails about the CincyKids Health Connect services. You may opt out of marketing emails by contacting us at email@example.com.
- I agree that I will be responsible for any hardware, telecommunications, and computing environments that are necessary for accessing the System in a manner supported by Provider, Teladoc and the other System Third Parties. I understand and agree that I am responsible for all connection and line charges, including long distance and roaming charges that are not included as a part of the System provided to me by Provider as a part of the CincyKids Health Connect.
- I agree that I will control my usernames and passwords as private and confidential information, and shall not permit use of my usernames or passwords in connection by any third party except as approved by the Provider in advance in writing. I understand and agree that I am responsible for and shall ensure adequate security over my password and account information, including by securing any computing systems or access devices I use to access the System, and am solely responsible for any misuse or unauthorized use of my account.
RELIABILITY OF COMMUNICATIONS NETWORKS: I understand and agree that neither the Provider nor Teladoc controls the system that provides the internet connectivity for the System or the availability of service for any computer or electronic device. I understand and agree that neither the Provider nor Teladoc is responsible for any mistake or lack of signal or service because of those systems. I also understand and agree that neither the Provider nor Teladoc is responsible if one of those systems breaks any laws related to the way information is sent using any computer or other electronic device.