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Consent Forms

As You Are Consent Forms

In order for As You Are to provide telehealth services for your family, we’re required to have a number of consents on file. Below, are the individual consents that you will be asked to acknowledge when you schedule an appointment. If you would like a copy of your signed consent, please reach out to the support team at

Virtual Care Registry Consent

HIPAA Notice of Privacy Practices

Informed Consent for Telehealth Services

Assignment of Benefits and Designation of Authorized Representative

Informed Consent for Electronic Communication

Financial Policy

Card on File Agreement

Virtual Care Registry Consent Form

Virtual Care Study Consent Form

Consent to Obtain PHI

Consent to Release PHI

Notice and Acknowledgement Regarding Medical Doctors in California

Minnesota Access to Health Records Notice of Rights

We Accept

Aetna • Blue Cross Blue Shield • Medicaid • TRICARE • United Healthcare

Don’t see your health insurance provider listed? Don’t get discouraged! We work with commercial insurance plans, TRICARE, traditional state Medicaid plans and managed care partners. We are constantly expanding our relationships as we grow. And, as a part of our process, our support team will review a child’s insurance benefits with their parent or guardian before the first appointment. To get started families can submit this form or contact our support team at 866.219.8595. Participation may vary by state and each child’s health insurance benefits.

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