I affirm that I am the parent or legal guardian of the minor child receiving care and that I have legal authority to consent to medical care for this child. If custody of the child is shared, I affirm that I have the authority to consent to this care, and I agree to notify Nabi Health promptly if my authority to consent changes or is contested.

I do hereby agree and give my consent to Nabi Health to provide health and medical care and treatment considered necessary and proper to my child/ward, in diagnosing and/or treating the physical and mental condition of my child/ward.

I understand that I have the right to refuse any medical treatment or procedure for my child/ward, and that I may discuss any and all medical treatments or procedures with their healthcare provider.

I understand that Nabi Health delivers care via telehealth, meaning my child/ward's provider uses electronic video and communication technology to provide services while my child/ward and the provider are in different locations. I consent to my child/ward receiving health care services from Nabi Health via telehealth through Healthie, a secure, HIPAA-compliant platform.

I understand that the laws that protect the privacy and confidentiality of my child/ward's medical information also apply to telehealth.

I understand that while telehealth has been found to be effective for a wide range of conditions, there is no guarantee that treatment will be effective for every patient.

I understand that telehealth involves technology risks, including internet interruptions and technical difficulties with hardware, software, or internet connection that may interrupt a session, and that Nabi Health does not guarantee that services will be available or work as expected.

I understand that I am responsible for information security on my own devices, for keeping my account username and password private, and for ensuring that my child/ward joins sessions from a private location where others cannot overhear.

I understand that my child/ward's provider or I may discontinue telehealth services if this type of service delivery is not meeting my child/ward's needs.

I do hereby authorize Nabi Health to release any information acquired in the course of the minor's examination(s) and treatment(s) to any authorized agent for the purposes of healthcare, treatment, and payment.

I allow Nabi Health to file a claim for insurance benefits to pay for the care that my child/ward receives. I authorize Nabi Health payment of benefits directly to Nabi Health, for services provided to my child/ward.

I understand the following:

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  Nabi Health will send the medical record information of my child/ward to the insurance company in order to file for insurance benefits for the care provided.

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  I will be responsible for paying any amount for the cost of these services that insurance does not pay.

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  I will be responsible for paying the full cost of these services if my child/ward does not have eligible insurance.

I understand that there may be some risks to my child/ward including, but not limited to emotional distress related to discussing food, body weight, or health history; the potential for temporary changes in appetite or energy levels as dietary habits shift; and the risk that nutritional recommendations may interact with undiagnosed medical conditions or medications if not fully disclosed.

If you or your child/ward have a medical emergency, please call 911, or go to your nearest hospital emergency department. If you or your child/ward experience a mental health crisis or need to speak to someone, please call or text the 988 Suicide & Crisis Lifeline at 988 at any time.

I understand that Nabi Health is permitted or required, under specific circumstances, to use or disclose protected health information without my written authorization. These include: suspected child or elder abuse or neglect; a serious threat of physical harm to the patient or others; or in response to a legal court order or subpoena.