1. I understand that telehealth services involve the use of information and communication by a health care provider to deliver services to an individual when he/she is located at a different site than the provider, and hereby consent to engaging in telehealth services with Full Spectrum Behavior Analysis (FSBA) and its providers.
2. I consent to {typeA} (BCaBA, BCBA, BCBA-D) providing telehealth services to my child (and his caregivers) and on-site ABA providers (i.e., Board Certified Associate Behavior Analysts, behavior technicians) for the purposes of caregiver training, staff supervision, and general case consultation.
3. I understand that telehealth services will not be the same as on-site, in-person services from a BCBA due to the fact that I will not be in the same location as the Behavior Analyst.
4. I understand that there are potential risks related to the use of technology, including interruptions, unauthorized access, and other technical difficulties. I understand that all local, state, and federally mandated security and confidentiality safeguards will be in place to ensure that any technology use and related procedures are in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
5. I understand that I may benefit from telehealth services; for example, in the form of more frequent contact with a Behavior Analyst; however, these results cannot be guaranteed or assured.
6. I understand that the Behavior Analyst or I can discontinue telehealth services temporarily or permanently if it is felt that the present environment renders these services unsafe or if present resources are inadequate for the delivery of these services. I further understand that if FSBA believes that I would be better served by another therapeutic arrangement, I will be referred to a source that may provide such services.
7. The Behavior Analyst or another ABA provider on my case has informed me of how telehealth equipment functions, and that my personal wireless Internet will be used in conjunction with their equipment. I understand that I am still responsible for any subscription costs or other costs needed to maintain my personal wireless Internet, and that no compensation or reimbursement will be provided for Internet data usage during the provision of telehealth services.
8. I understand that I will be responsible for the same number and costs of copayments or coinsurances that apply to in-person Behavior Analyst services, when receiving telehealth services.
By signing this form, I certify:
• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.