Online Speech Therapy Consent
1. The purpose of this form is to obtain your consent for your child to participate in teletherapy for Speech/Language and/or Feeding Therapy. Teletherapy uses interactive video, audio and telecommunication technology.
2. Medical Information and Records: All existing laws regarding your access to medical information and copies of your medical records apply to telehealth. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this telehealth interaction shall not occur without your consent. * Video, audio and photo recordings may be taken of you during the session, but will NOT be used or stored by Talk to Me...A Speech Therapy Co., LLC
3. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during the telehealth session.
4. Rights: You may withhold or withdraw consent to telehealth at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
5. Disputes: You agree that any dispute arriving from telehealth session will be resolved in Georgia, and that Georgia law shall apply to all disputes.
6. Risks, Consequences and Benefits: You have been advised of all the potential risks, consequences and benefits of telehealth. Your healthcare professional has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telehealth session. All your questions have been answered and you understand the written information proviced above.