Informed Consent for Telehealth Services

I understand that telehealth is the use of electronic information and communication technologies a health care provider to deliver services to an individual when he/she is located at a different by site than the provider; and hereby consent to Journey Pediatric Therapy providing occupational therapy services to me via telehealth as mutually agreed upon by the therapist and me. Telehealth may be used in situations where face-to-face therapy is impractical or impossible due to, but not limited to, weather conditions or illness.

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. I understand that telehealth sessions can only take place over a secure platform that is also Health Insurance Portability and Accountability Act (HIPAA) compliant.

I hold Journey Pediatric Therapy harmless for any information lost during a telehealth session due to technical failures.

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my/my child's right to future care or treatment. I may revoke my consent in writing at any time by contacting Journey Pediatric Therapy, P.O. Box 2476, Sandpoint, ID 83864. As long as this consent has not been revoked, Journey Pediatric Therapy may provide occupational therapy services to me via telehealthas mutually agreed upon without the need for me to sign another consent form.