Informed Consent for Telehealth Services

You have chosen to receive care through the use of Telehealth. Telehealth enables heath care providers at different locations to provide safe, effective, and convenient care through the use of technology. As with any health care service, there are risks associated with the use of Telehealth, including equipment failure, poor image resolution, and information security issues.

By signing this form, I understand the following:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me/my child will be disclosed to anyone without my consent. The online connection used by Starfish Therapies meets required privacy standards and the only person present during treatment will be the child’s authorization therapist. The therapist is in a private room during treatment and the screen cannot be seen by unauthorized people.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my child’s care at any time, without affecting my right to future care or treatment.

I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. Starfish Therapies has explained the alternatives to my satisfaction.

I understand that I may expect the anticipated benefits from the use of telemedicine in my child’s care, but that no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine, have discussed it with my therapist, and all my questions have been answered to my satisfaction. I hereby authorize Starfish Therapies to use telemedicine in the course of my child’s treatment.