Telehealth Informed Consent
As a client receiving Outpatient Therapy (Physical, Occupational and Speech), Early Intervention, Mental Health Counseling, Psychology and/or Behavioral Health telehealth methods, I understand that:
Telehealth is the delivery of therapy services using interactive technologies (audio, video or other electronic communications) between a provider and a client that are not in the same physical location. The interactive technologies used in Telehealth incorporate network and software security protocols to protect the confidentiality of patient information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. By participating in the Telehealth method provided by Pediatric Partners I acknowledge:
This service is provided by technology (included but not limited to video, phone, text and email)
and may involve direct face to face communication.
1. I will need access to, and familiarity with, the appropriate technology in order to participate in the service
2. The information obtained and provided is through electronic means.
a. During your virtual care consultation, details of your medical history and personal health
information may be discuss with you and your health care professionals.
3. I may decline or discontinue any telehealth services at any time without jeopardizing my access
to future care,
services or benefits.
4. Telehealth which allows for great convenience in service delivery; however, there are risks in
5. The patient’s plan of care will be regularly reassessed and delivered to me using the Telehealth
with modifications to plan as needed.
7. Due to the payor source Pediatric Partners may be required to provide telehealth medical
8. Medical documents will be maintained in accordance to the HIPAA regulations.
9. The laws and professional standards that apply to in-person outpatient services also
apply to telehealth services. This document does not replace other agreements, contracts,
or documentation of informed consent.
Printed Name of Parent, Guardian, or Patient (if over 18 years of age)