TheraKids Plus, Inc. Telemedicine Consent Form - English Consent to Participate in a Telepractice (Telehealth) with Therakids Plus, Inc.Patient Name: DOB: MM slash DD slash YYYY 1. I understand that, due to COVID-19 mandates, speech/occupational/physical therapy and/or early intervention services will be provided via Telepractice sessions, evaluations or consultations. This means that my therapists or early interventionist and I, or a designee will, through an interactive audio/video connection, be able to consult with my or my child’s therapist/ITDS.2. My health care provider has explained to me how the video conferencing technology will be used. I also understand that my therapist(s)/ITDS will be using HIPAA compliant technology and, at no time, will my session be shared knowingly with others (unless authorized by the patient or caregiver). I understand that at times a supervising therapist may join in my session.3. I understand that Telepractice will not be the same as an “in-person” visit since I will not be in the same room as the therapist/ITDS, and that some parts of a session, evaluation, or consultation may be conducted by individuals present with me, or my designee, at the direction of the consulting therapist/ITDS. Sessions may include activities such as, assessment, treatment programs, printing of delivered documentation, planning for next session, etc...4. I understand there are possible risks of an incomplete or ineffective consultation because of the technology, and that if any of the risks occur, the consultation may terminate. The risks may include failure, interruption or disconnection of the audio/video connection; a picture that is not clear enough to meet the needs of the consultation; and a minor risk of access to the consultation through the interactive connection by electronic tampering5. I understand that in place of this Telepractice session I may seek face-to-face consultation with a therapist/ITDS, if circumstances permit (i.e., COVID-19 mandates).6. I have read and understand this consent and all of my questions have been answered to my satisfaction. I understand the mandate for Telepractice services secondary to COVID-19, the differences between in-person and Telepractice sessions, my responsibilities regarding the process, the benefits of on-going telemedicine consultation/therapy, and consent to it.Patient/Representative Signature:Date MM slash DD slash YYYY Representative Name: Relationship: EMAIL TO: [email protected] or FAX TO: 813-873-8837
