SECURE FORM

San Benito CISD Registration Form

Terms & Conditions

For Office Use Only
For Office Use Only
Do You Agree To The Terms & Conditions Above?*

NOTICE:


You must agree to the Terms & Conditions to proceed to register yourself or your child for the telemedicine program.

Patient Information

Who Is The Patient That Is Being Registered?*

Basic Information

Student's Information

VCFF Registration Form

By completing this form I am declaring that I would like my child to participate in the San Benito CISD telemedicine program, operated by Urgent Care for Kids (Doing Business As: Virtual Care for Families), a service of Pediatric Urgent Care, PA affiliated with Urgent Care for Kids, and agree for him/her to be treated via telemedicine at school. San Benito CISD is NOT responsible for the cost of treatment provided in this program. All costs will be paid by your health insurance company and you.

Student's Name*
Student's Date of Birth*
Month, Day, Year (MM/DD/YYYY)
Type "Unknown" if you don't know.
Is the Student in School Sport or Activities?*
Student's Address*
Student's Birth Sex*
Student's Race*
Check all that apply
Is the Student Hispanic or Latino?*

Parent/Guardian Information (Primary Guardian)

Primary Guardian’s Full Name*
Primary Guardian’s Date of Birth*
Month, Day, Year (MM/DD/YYYY)
Father, Mother, Aunt, Grandmother, etc
Please use your cell phone number if possible to receive text messages about your appointment.
Primary Guardian’s Phone Type*
It's important to use a working email address as your instructions may be emailed to you.
Guardian's Birth Sex*
Primary Guardian’s Address*

Basic Information

Patient Information

VCFF Registration Form

By completing this form I am declaring that I would like to participate in the San Benito CISD telemedicine program, operated by Urgent Care for Kids (Doing Business As: Virtual Care for Families), a service of Pediatric Urgent Care, PA affiliated with Urgent Care for Kids, and agree to be treated via telemedicine at school. San Benito CISD is NOT responsible for the cost of treatment provided in this program. All costs will be paid by your health insurance company and you.

Patient's Name*
Patient's Date of Birth*
Month, Day, Year (MM/DD/YYYY)
Please use your cell phone number if possible to receive text messages about your appointment.
Patient's Phone Type*
It's important to use a working email address as your instructions may be emailed to you.
Patient's Address*
Patient's Birth Sex*
Patient's Race*
Check all that apply
Are you Hispanic or Latino?*

Emergency Contact

Emergency Contact Name (Only add if different than the Primary Guardian/Patient)
Emergency Contact’s Address

Patient's Primary Care Physician and Pharmacy Information

Name of Primary Care Physician
Consent to share your health record with your primary care physician?

Patient's Medical History

Please write NONE if the child is not taking any medications
Please write NONE if the child does not have any known allergies
Does the patient have any of the following conditions?*
Is the patient pregnant? *
Does the patient have any Surgeries? *
Does the patient have any family medical history that's important to note?*

CARES Act Insurance Question

We will file your insurance to cover the cost for you or your child to receive a rapid COVID-19 test. There are no out of pocket expenses at this time under the Families First Coronavirus Response Act and the CARES Act. 

Does the patient have private insurance?*
Does the patient have Medicaid or Medicare?*

If the patient is uninsured, you may qualify under the CARES Act

To participate in this government program, you must meet the requirements of the terms and conditions.

  • The patient must have a Social Security Number or equivalent
  • By completing this form, you confirm that you DO NOT have private insurance of any kind.
  • You are NOT enrolled in any government medical insurance programs such as Medicaid and Medicare.
  • You are above the age of 18 and this medical visit is for you alone OR you are filling this form out as a parent, guardian, or legal custodian of a child.
  • The United States CARES Act only covers costs associated with COVID-19 Screenings and labs related to COVID-19. CARES Act DOES NOT cover medications prescribed associated with the telemedicine visit or lab tests not related to COVID-19.
  • If the patient has any form of insurance but does not want to use that insurance, the patient is NOT ELIGIBLE for this free visit.
  • You agree to have your information verified and be billed at full price if your information is falsified.
Do you feel you the patient has met the qualifications for these terms and conditions?*

Payment Information

Please Read:


Per guidance from the recently passed CARES Act, insurance companies may not require out of pocket patient portion for COVID testing which intends for a $0 cost for anyone receiving COVID testing when guidelines are met. We fully expect these visits to qualify for $0 cost test (fully covered by insurance), however, we still need to invoice the patient/guardian in the unexpected instance that the insurance carrier does cover the cost and pushes the cost of the COVID-19 test to the patient. Since the guidelines were released insurance companies have been covering the visit in full resulting in $0 cost to the patient.    

Also, if the patient is treated for any non-COVID-related services normal copays, coinsurances and deductibles may be applied and your invoice and will be charged in that instance.

Payment & Insurance

Select your correct insurance, or self-pay, or select "Other" if not listed.
Because you selected "Other" for your insurance company please type the company name in this box.
Include Letters & Numbers before and after the policy number if any.
Write "NA" if you don't have one.
Write "NA" if you don't have one.
Is the patient the insurance holder?*
If NO, what is the policy holder’s name?*
Policy Holder’s Birth Sex*
Policy Holder’s Date of Birth*
Month, Day, Year (MM/DD/YYYY)
Do you have secondary insurance?*

Secondary Payment & Insurance

Select your correct insurance, or self-pay, or select "Other" if not listed.
Because you selected "Other" for your secondary insurance company please type the name in this box.
Include Letters & Numbers before and after the policy number if any.
Write "NA" if you don't have one.
Write "NA" if you don't have one.
Secondary Insurance - Is the patient the insurance holder?*
Secondary Insurance - If NO, what is the policy holder’s name?*
Secondary Insurance - Policy Holder’s Birth Sex*
Secondary Insurance - Policy Holder’s Date of Birth*
Month, Day, Year (MM/DD/YYYY)

Preferred Method of Communication

Do you authorize us to send information regarding your testing results via email?*

Important Note:

By selecting "no" you can delay your testing results by up to 72 hours. Depending on your school district this may impact your ability to participate in sports and activities while waiting for your results. 

My preferred method of communication regarding my conditions is indicated below:

If the above method of communication is by phone, please check one of the appropriate box below:

If you select text message or email as the preferred method of communication, you are providing consent for Urgent Care for Kids/Virtual Care for Families to send you periodic text messages or emails regarding the patient. By consenting below, you understand there is a risk that information contained in these text messages and emails could be read by a third party since these messages are not protected by encryption technology. By signing this form, you acknowledge and agree to receive text messages and emails related to the patient’s medical information that may not be secure.

Please note that you are responsible for any charges incurred in receiving our communications. For example, if you provide a cell phone number as a method of contact, then you are responsible for any charges imposed by your mobile carrier for receiving calls or text messages from the clinic. Please let our office know if you have any special directions or requests regarding our communication with you. For example, please let us know if you would like us to call you at a different phone number for a particular test result or if you do not want to be called at all.

Additional HIPAA Contacts

Keeping our patient’s information private is important to us and by default, we will only disclose information related to the patient’s medical conditions to the patient, legal guardian, or as otherwise authorized by HIPAA. We will only disclose information related to the patient’s billing account to the patient and legal guardian, or as authorized by HIPAA.

If you would like to add additional contacts (other than the patient or legal guardian) to receive this type of information, please complete the fields below and select the appropriate boxes based on the information you would like this contact to receive.

HIPAA Approved Contact 1
For example: Parent, Grand Parent, Uncle, Aunt, Etc
HIPAA Approved Contact 1 Has Permission To:
HIPAA Approved Contact 2
For example: Parent, Grand Parent, Uncle, Aunt, Etc
HIPAA Approved Contact 2 Has Permission To:

The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for health information from persons not listed on this form will require my specific authorization prior to the disclosure of any health information unless it is authorized by HIPAA.

Consent to Exchange Personal Information with Health Staff
You authorize Urgent Care for Kids/Virtual Care for Families to exchange the patient’s personal information, which may include information about the patient’s medical condition, with health staff in compliance with applicable law, including HIPAA and the federal Family Educational Rights and Privacy Act a/k/a FERPA.

Consent to treat

I consent to treatment of the child whose name is: *

Consent for Medication Administration

  1. I hereby authorize employees and agents of Urgent Care for Kids/Virtual Care for Families, including providers and other staff members to render medical evaluation and treatment to the patient listed on this form.
  2. I understand that our services are or may be provided through telemedicine and/or telehealth, through a combination of audio, visual and store and forward technology and are not appropriate for all medical issues and should not be used in emergency situations.
  3. I understand that there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to, delays in medical evaluation and treatment due to limitations, deficiencies and/or failures of the technology. Additionally, in rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
  4. I agree by accepting the services that the patient listed on this form is entering into a patient-provider relationship with the healthcare provider(s) that Urgent Care for Kids/Virtual Care for Families assigns to the patient.
  5. I understand that the services provided by Urgent Care for Kids/Virtual Care for Families do not replace an existing primary care physician relationship and, in certain instances, will require follow-up care with a local healthcare provider.
  6. I understand that the testing may involve the collection of bodily fluids or tissue (each a “Sample”), in accordance with standard testing procedures.
  7. I understand that while the tests performed on the patient’s Samples are approved by regulatory agencies and designed to detect the presence or absence of a specific disease or infection, they are not perfect or absolute. There is a statistical possibility that a test may yield a false positive or a false negative test result, which could result in an inadvertent misdiagnosis or delay in treatment.
  8. I hereby authorize our health staff to carry out orders and treatment plans as directed by Urgent Care for Kids/Virtual Care for Families providers to the patient listed on this form.
  9. I understand that by not signing this consent, this patient will not be provided with medical care by Urgent Care for Kids/Virtual Care for Families.


Consent for Medication Administration

  1. I hereby authorize our health staff to administer over-the-counter and prescription medication at the direction of a physician to the patient listed on this form in connection with orders and treatment plans directed by Urgent Care for Kids/Virtual Care for Families.
  2. I acknowledge that I have read the medication administration information earlier in this registration form.
  3. I agree to review and will provide any special instructions for the administration of the medication of the patient listed on this form and share that information with the patient’s school health staff.
  4. The duration of this consent lasts the discontinuation of active treatment under the patient-provider relationship.


By signing below, I acknowledge that I have been provided a read and understood the document in its entirety, including the below. 

Notice of Privacy Practices

Preferred Method of Communication

Additional HIPAA Contacts

Financial Responsibility

Consent to Treat

Consent for Health Staff to Authorize Treatment

Consent for Medication Administration


This consent/authorization may be withdrawn in writing at any time.

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