Skip to content
Call: 1.888.875.5262

|Contact Us

Facebook page opens in new windowLinkedin page opens in new window

Patient Portal

|Join Telehealth Session

|Make A Payment

Request Free Screening
Pediatric Partners – Children's Therapy & Counseling
Reaching Further
Pediatric Partners - Children's Therapy & CounselingPediatric Partners - Children's Therapy & Counseling
  • About Us
  • Services
    • Therapy Services for Children
      • Occupational Therapy
      • Physical Therapy
      • Speech-Language Therapy
    • Mental Health Counseling
    • Applied Behavior Analysis
    • Free Screening
    • Request A Free Screen
    • Early Intervention
  • Parent Resources
    • Frequently Asked Questions
    • Developmental Milestones
    • Testimonials
    • Your First Visit
  • Patients
  • Locations
    • Fargo, ND
    • Bismarck, ND
    • Grand Forks, ND
    • Thief River Falls, MN
  • Careers
    • Mental Health Team
    • Student Internships
  • News & Events
Search:
  • About Us
  • Services
    • Therapy Services for Children
      • Occupational Therapy
      • Physical Therapy
      • Speech-Language Therapy
    • Mental Health Counseling
    • Applied Behavior Analysis
    • Free Screening
    • Request A Free Screen
    • Early Intervention
  • Parent Resources
    • Frequently Asked Questions
    • Developmental Milestones
    • Testimonials
    • Your First Visit
  • Patients
  • Locations
    • Fargo, ND
    • Bismarck, ND
    • Grand Forks, ND
    • Thief River Falls, MN
  • Careers
    • Mental Health Team
    • Student Internships
  • News & Events

Telehealth Informed Consent

Form Submission is restricted
Form is successfully submitted. Thank you!
Telahealth
.


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 provided. 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 transmitting information. 5. The patient’s plan of care will be regularly reassessed and delivered to me using the Telehealth with modifications to plan as needed. 6. As per Pediatric Partners privacy policy, discussion of client/patient information is prohibited unless authorized. 7. Due to the payor source Pediatric Partners may be required to provide telehealth medical documentation. 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.

Patient's Printed Name
Printed Name of Parent, Guardian, or Patient (if over 18 years of age)
Relationship to Patient
Date
 
Contact Us
  • Phone:
    1-888-875-5262
  • Fax:
    (701) 232-2330
  • Email:
    [email protected]

Find us on:

Facebook page opens in new windowLinkedin page opens in new window
About Us

Pediatric Partners provides Physical Therapy, Occupational and Speech-Language Therapy, Mental Health Counseling, Applied Behavior Analysis, and Early Intervention services to children in-clinic, in-home, or through Telehealth in North Dakota and Minnesota.

Locations

Fargo, ND Clinics
Bismarck, ND Clinic
Grand Forks, ND Clinic
Thief River Falls, MN Clinic

Services

Early Intervention
Mental Health Counseling
Physical Therapy
Speech Language Therapy
Occupational Therapy
Applied Behavior Analysis (ABA)
Behavior Consultation
Autism Waiver Management

Footer Services

© Pediatric Therapy Partners | Privacy Policy

Go to Top