● I understand that my health care provider, RDV Sportsplex Pediatrics, has TELEHEALTH technology as one of the options to help diagnose the patient OR when I’m not comfortable taking the patient out of the self-quarantine or simply prefer to stay home and isolate the patient from public areas and offices.

● I understand I have the right to refuse to participate in any telehealth encounter at any time or to end at any point during the encounter. I understand that if I don’t want to participate in a telehealth encounter, I will need to either make an appointment for an in-person with my Healthcare provider or Seek care at the closest emergency department if I believe that my symptoms warrant that level of care. Moreover, I understand that my healthcare provider may not be able to accommodate  in-person visit the day of my request (for the cases of office closures)

● I Understand that for TELEHEALTH, there is a scope of limitations as to the type of services and assessments that can be performed and therefore there may be several Diagnoses that cannot be determined via TELEHEALTH.

● I understand that my healthcare provider can discontinue Telehealth Care if the healthcare provider believes that this technology doesn’t meet the standard of care necessary to address my medical concerns. If that happens, I understand that I will need to make an In-person Appointment or go to the closest Emergency Room or Urgent care for services.

● I understand that we might have the possibility of technical difficulty if internet service at the Patient location or at our office is busy or signal is not adequate to pursue the Telehealth encounter.

● I understand that I will be responsible for any copay and coinsurance that applies to Telehealth visits. I understand I may have questions and Our Practice advises me to check directly with my insurance provider.

This consent remains valid and acceptable for a period of 1 year (12 Months) from the day of my Initial Telehealth.