2022 - 2023 Healthy @ Schools for Pikeville Independent

Telehealth Services for Students

for 2022 - 2023 911 Bypass Rd., Pikeville, KY 41501 | 606-430-3500 | pikevillehospital.org

PMC OFFERS HEALTH CARE FOR YOUR CHILD AT SCHOOL Pikeville Medical Center (PMC) offers telehealth services for students, allowing them to be seen virtually by a medical provider without having to leave school.

In most cases, parents or guardians are able to pick their sick child up from school, pick up any necessary prescription medication from the pharmacy and go directly home.

Parents/guardians are required to sign the necessary documents contained in this booklet, giving PMC the authorization to examine the student with assistance of the school nurse.

This service is not intended to replace the student’s regular primary care provider, but to give him/her access to health care conveniently while at school.

Dear Parent or Guardian, As we send our children to school, we all take comfort in knowing our school systems are educating and equipping our children to succeed in life. I am proud Pikeville Medical Center partners with our local school systems to offer the “PMC Healthy @ School Telehealth Program.” This program will enable your child's health care needs to be addressed by one of our professional medical providers while he or she is in school.

From Head Start to senior year, if a child becomes ill while in school, a visit to a medical provider could be necessary. However, your child can see a provider through the Healthy @ School telehealth program with our partnership. In many ways, it is very similar to a traditional in-person visit.

With this system, a PMC medical provider will communicate with the school designee as they see your child through a high-definition medical video teleconferencing system provided by us. With the aid of this advanced technology, the provider will have the ability to look into your child's eyes, ears and/or throat. Other medical equipment used with this advanced system, such as a stethoscope, will enable the medical provider to listen to your child's heartbeat and breathing, if or when necessary.

PMC will offer quick and easy access to health care during school hours to children attending inperson classes in this school district. In many cases, you could pick your child up from school, get any necessary prescription medication from the pharmacy and go directly home for your child's recovery. This will avoid travel time to a provider's office along with potential exposure to other illnesses for your child, who wants nothing more than to go home, rest and feel better. Additionally, since PMC accepts all insurance plans, your child's telehealth visit will be covered.

Pikeville Medical Center is intensely committed to enhancing pediatric medical services to the region we serve. In 2020, PMC opened the AVA Center, which is now one of the nation's largest pediatric autism centers utilizing ABA therapy. In December 2021, we opened the Mettu Children's Hospital, the first children's hospital in Eastern Kentucky. It is with great pride that we are also able to offer the PMC Healthy @ School Telehealth Program to the students, faculty and staff at your child's school again this year.

Please read and complete the enclosed documents for your child to participate in this program and then return them to your school administrator.

Sincerely,

Donovan Blackburn,

NOTICE OF PRIVACY PRACTICES

You may revoke INFORMED CONSENT FOR SCHOOL-BASED TELEMEDICINE SERVICES form at any time by sending a written revocation to doris.taylor@pikevillehospital.org. Pikeville Medical Center may rely on this document as your continuing consent to treat your child until such a revocation is received.

Informed Consent for School-Based Telemedicine Services Telemedicine involves delivery of health care from a distance when the provider and the patient are not in the same physical location. This service uses information technology to provide medical care.

Telemedicine services can be used to provide services such as routine office visits, prescription refills, new prescription for non-narcotic medications, or patient education.

Special equipment will be used to securely store and transmit your child's health information to a remote location.

Providers there will review the information. If needed, a secure computer connection can provide two-way picture and sound communication with these providers for consultations and information for the purpose of providing or improving patient care.

The information may be used for diagnosis, therapy, follow-up and/or education, 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 Security measures to protect your child's information will include the utilization of data encryption and unique user logins and passwords.

As part of your child's treatment or to obtain payment for your treatment, it may be necessary to forward patientidentifiable information to a third party.

The use of Telemedicine has these expected benefits: A telemedicine visit may help your provider to diagnose your child's condition. It may also help the provider to make an appropriate treatment plan. Your child may avoid having to travel for in-person care.

As with any medical procedure, there are potential risks associated with the use of Telemedicine.

These risks include, but may not be limited to: 1. The service may not cure or relieve your child's condition or symptoms.

2. The use of telemedicine may not find all the problems, diseases, or abnormalities you child may have.

3. The provider may not be able to complete the service for various reasons including the transmission of information may not be sufficient (for example, poor resolution of images).

4. The provider may not be able to make a proper diagnosis or medical evaluation and treatment may be delayed due to equipment failure.

5. Your child's medical information may be lost due to technical failures of the telemedicine equipment.

6. In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

7. Pikeville Medical Center, Inc. has installed security measures with the use of telemedicine to prevent unauthorized access to your child's medical information transmitted via telemedicine. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

8. Your child may need additional tests or treatment which will require travel to a medical facility. In the case of emergency, a provider may advise that your child needs to receive emergency or acute medical care at the nearest facility.

Alternatives: Alternatives to a telemedicine visit include: · · ·

Watching and waiting.

Traveling to a location where in-person medical care is available.

Choosing not to use this service.

By accepting these terms, you acknowledge and agree to the following: 1. You hereby authorize Pikeville Medical Center its employees and staff to provide medical services to your child and to treat your child's condition using Telemedicine services. A description of provider qualifications is available at www.pikevillehospital.org.

2. You understand that while, Pikeville Medical Center will make reasonable attempts to contact you when your child presents for medical care via Pikeville Medical Center's school-based telehealth program, it may not be possible to reach you at that time and Pikeville Medical Center and its employees and staff are still authorized to treat your child even if attempts to reach you at the time are unsuccessful.

3. You understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of Telemedicine, which identifies your child, will be disclosed to researchers or other entities without your consent or as permitted by law.

4. You understand that you have the right to review and have been provided a copy of the Notice of Privacy Practices for information about how your child's protected health information may be used and disclosed and that you may also contact the Pikeville Medical Center Privacy Officer, 606-218-3542, at any time with any questions about the Notice of Privacy Practices and/or your child's protected health information.

5. You expressly hereby authorize Pikeville Medical Center and its employees, to share your child's information for the purposes of to provide treatment to you and to obtain payment for services provided.

6. You understand that Telemedicine may involve electronic communication of your child's personal medical information to other medical practitioners who may be located in other areas, including out of state.

7. You agree to hold Pikeville Medical Center, Inc. and its employees harmless for any medical information which may be lost.

8. You understand that you have the right to inspect all information obtained and recorded in the course of a Telemedicine interaction, and may receive copies of this information. There may be a reasonable charge for copies.

9. You understand that you have the right to withhold or withdraw your consent to the use of Telemedicine in the course of your child's care at any time without affecting his/her right to future care or treatment.

10. You understand that a variety of alternative methods of medical care may be available, and that you may choose one or more of these at any time.

11. You understand that it is your duty to inform Pikeville Medical Center of information concerning your child's medical history by completing the forms and questionnaires associated with Pikeville Medical Center's school-based telehealth program and to update this information when it changes by providing written updates to your child's school nurse and authorizing the school to share this information with Pikeville Medical Center.

12. You acknowledge that the decision of whether or not your child's medical condition can be appropriately treated via telemedicine is made by the provider and that the provider may determine that your child's condition is not suitable for telemedicine.

13. You authorize Pikeville Medical Center to bill your health insurance (if applicable) for the telemedicine services and to act on your behalf for insurance appeal purposes.

After reading these documents, please sign the yellow highlighted sections, detach and return to your child’s school.

14. You acknowledge that you are responsible for any charges not covered by your insurance and are further responsible for interest on any unpaid balance and the costs incurred by Pikeville Medical Center to collect amounts owed by you including a reasonable attorney's fee.

15. You authorize Pikeville Medical Center, Inc., its service providers (including service providers contacting you about obtaining potential financial assistance for your account(s) and/or for collection services) and their agents to contact you at any telephone number associated with your account(s), including wireless telephone numbers or other numbers that result in charges to you, whether provided in the past, present or future. You agree that methods of contact may include using pre-recorded or artificial voice messages and/or an automatic telephone dialing system, as applicable.

16. You authorize Pikeville Medical Center, its employees, agents and/or medical staff members to communicate with you via any electronic means including texting, email and other forms of communication which may pass through technology outside the control of Pikeville Medical Center and such technology may not be confidential or secure.

17. You authorize Pikeville Medical Center to email to you a summary of your child's visit to the email address you provide.

18. You authorize your child's school nurse or other personnel designated by your child's school to assist Pikeville Medical Center's providers in the provision of medical services to your child and acknowledge that these individuals are not Pikeville Medical Center employees and, therefore Pikeville Medical Center is not responsible for their actions. You authorize Pikeville Medical Center and school personnel to share information about your child for the purpose of providing medical services to your child.

19. You understand that, if English is not your or your child's first language, an interpreter and or translation services are offered and available to be provided to you.

20. You understand that your child may expect the anticipated benefits from the use of Telemedicine in his/her care, but that no results can be guaranteed or assured.

21. You understand that you can revoke this consent at any time by sending a written revocation to melissa.thacker@pikevillehospital.org, but that Pikeville Medical Center may rely on this document as your continuing consent to treat your child until such a revocation is received.

Child's Name: ____________________________________

_________________________________________________ Signature of Parent or Guardian

__________________________ Date

_________________________________________________ Print Name of Parent or Guardian **If you are not the child's parent, please include documentation verifying your ability to consent for the child.

SCHOOL/HOMEROOM:________________________________________________________

GRADE : ______________

CONSENT FOR SCHOOL HEALTH SERVICES/MEDICATION ADMINISTRATION PIKE COUNTY HEALTH D EPARTMENT /PIKE COUNTY SCHOOL SYSTEM /PIKEVILLE INDEPENDE NT SCHOOLS CHILD'S NAME :_____________________________________ BIRTHDATE :____________ GENDER ___________ RACE : _______________ ADDRESS :__________________________________________________________________________________________________________________ CHILD’S SOCIAL SECURITY #: ____________________________________ PARENT/LEGAL GUARDIAN :

___________________________HOME PHONE:__________________WORK PHONE :________________

DO YOU PREFER TO REVCEIVE THE SUMMARY OF YOUR CHILD’S VISIT BY:

MAIL

E-MAIL

PARENT/GUARD IAN E-MAIL ADDRESS: ______________________________________________________________________________________ EMERGENCY CONTACT NAME :___________________________________________PHONE ___________________________________________ (Other than Parent)

MEDICAL INSURANCE CARRIER:_____________________________________CARD HOLDER’S NAME:__________________________________ POLICY ID#:___________________________________GROUP NUMBER:_________ NUMBER IN HOUSEHOLD :__________________________ STUDENT'S DOCTOR :__________________________________________________ DOCTOR’S PHONE:__________________________________ STUDENT’S DENTIST :___________________________________________________DENTIST’S PHONE:__________________________________ PHARMACY OF CHOICE: ________________________________________________PHONE NUMBER:___________________________________ SEIZURES ___________ _

ALLERGIES/ASTHMA (food, insects, medication, latex, fluoride, other)_____________________________________________

DOES YOUR CHILD REQUIRE AN EPI - PEN PRESCRIPTION FOR ANY ALLERGIES? YES _______ NO __________ CURRENT MEDICATIONS ________________________________________________________________________________________ CHRONIC MEDICAL ILLNESSES __________________________________________________________________________________ SIGNIFICANT MEDICAL / SOCIAL HISTORY (Including Injuries) _______________________________________________________ SIGNIFICANT FAMILY MEDICAL HISTORY Hypertension High Cholesterol Diabetes Other_______________________ Please check any of the following, which you will allow your child to be given, and state dosage if necessary. All doses not specified will be given according to the child’s age and weight using manufacturer’s guidelines.

Advil/Motrin (Ibuprofen)

Benadryl

Orajel (toothache) Chloraseptic (sore throat)

Aloe Vera (for burns)

Cold Remedies (cough syrup, decongestant)

Sun Screen (SPF 15 or above)

Antacids (Maalox, Tums, etc.)

Diarrhea Medication

Topical Antiseptics

Antibiotic Ointment (Neosporin)

Eye Drops (Visine, Murine, etc)

Tylenol (acetaminophen)

Anti Nausea/Anti V omiting

Hall’s Mentho -lyptus cough drops

Anti -itch Spray or Lotion (insect bites, etc.)

Hydrocortisone Cream (for itching)

Additional instructions of consideration :________________________________________________________________________________ The following information will aid the School Nurse in making an accurate assessment of your child in case of illness or emer gency. Please check the appropriate space if your child has ever had any of the following: Anemia

Asthma

Persistent Cough

Exposed to Tuberculosis

Birth Defects

Chest pain

Leukemia

Shortness of breath

Diabetes

Seizures

Sleep Problems

Head, Eyes, Ears, Throat Problems

Chicken Pox

Unexplained Weight Loss/Gain

Stomach or Bowel Problems

Blood Transfusion

Rheu matic Fever

Unexplained tiredness

Joint or Muscle Pain or Stiffness

Anaphylactic Episodes

IF THIS INFORMATION SHOULD CHANGE, PLEASE NOTIFY THE SCHOOL NURSE, IMMEDIATELY!!!

I consent to care at the school provided by the Pike Count y Health Department which may include screenings such as Scoliosis screening, vision and hearing exams, assessments, lab tests, treatment, first-aid, over the counter medicine, and any other health service given to me/my child by staff or agents of the Pike County Health Department. I understand that no guarantees are being made as to the effect of any exam or treatment on me/my c hild. I like-wise release the staff from any liability related to the administering of the above medications to my child so long as the treatment is provided according to the above instructions.

I authorize the school health clinic to release medical information about my child, as permitted by the Health Insurance and Portability and Accountability Act of 1996 (HIPPA), to his/her primary care provider and to share pertinent medical information (history of allergies or significant medical history) with school staff who may need to provide care to my child in an emergency. I understand that the sharing of this information is on a need to know basis only. I also understand that the information obtained for the school physical, including immunization information, will be released to my child’s school. If my child has Medicaid or KCHIP, I also authorize the school clinic to release this information to those agencies so that the Medicaid or KCHIP can be billed for visits to the school clinic . This permission can be revoked at any time. No services will be provided unless the signed form is returned. I agree to provide the agency nurse an order from my child’s physician for any prescription medications before they can be given.

I also understand by signing this consent, I acknowledge that I may request a copy of the Pike County Health Department’s Privacy Notice by calling the Pike County Heal th Department’s main office at 437- 5500 or have access to a copy of the Pike County Health Department’s Privacy Notice located at www.pikecountyhealth.com/v3/uploads/documents/pchd_hipaa_pp.pdf .

Signed:

X___________________________________________________ Prin ted:_____________________________________________________________ Date:______________________ (Parent or Guardian)

(Parent or Guardian)

PCHD 126

(Rev. 3/20/17)