1. I understand the laws that protect privacy and confidentiality of medical information also apply to Telehealth, and no information obtained in the use of Telehealth which identifies me or my child will be disclosed to any entities not involved in healthcare operations without my consent.
2. I understand I have the right to withhold or withdraw my consent to the use of Telehealth in the course of the care of my child at any time, without affecting my child’s right to future care or treatment.
3. I understand I have the right to inspect all information obtained in the course of a Telehealth interaction, and may receive copies of this information by contacting the Privacy Officer. I understand Telehealth video visits are not recorded or archived and therefore will not be available for review at a later date.
4. I understand there are other methods of medical care available to my child. I understand a Telehealth visit is not the same as a direct patient/medical care provider visit as my child is not in the same room as the provider.
5. I understand Telehealth may involve electronic communication of my child’s personal medical information to other medical practitioners at Interlachen Pediatrics or other medical practitioners involved in my child’s care.
6. I understand I may expect the anticipated benefits from the use of Telehealth in my child’s care, but that no results can be guaranteed or assured.
7. I understand the potential risks of this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the Telehealth visit if it is felt the videoconferencing connections are not adequate for the situation.
8. I understand Telehealth visits for my child will be billed to the insurance company on file with Interlachen Pediatrics. I understand coverage for Telehealth can vary and if not covered under my plan I will be responsible for payment. I understand I am responsible for any co-pays, co-insurance or deductible not covered by the insurance company.