1. I authorize and voluntarily consent to the participation and treatment of myself or child in a Telemedicine Consultation.
2. I understand that as a participating patient, my physician and I will communicate by interactive television (videoconferencing) with physicians and staff at Spring Pediatrics. I understand that medicine is not an exact science and there are no guarantees that can be made regarding outcomes and results of these examinations and treatments.
3. It has been explained to me how the video conferencing technology will be used to conduct a visit. I understand that this visit will not be the same as an in-person visit due to the fact that my child will not be in the same room as the healthcare provider. I also understand that I have the option to see a provider in person, if I chose.
4. I further understand that there are potential risks to telemedicine, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that either the healthcare provider or I can discontinue my child’s telemedicine health visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I understand it may be necessary and useful for others to be present during the visit other than my child’s healthcare team and provider in order to operate the video equipment. These individuals are bound to maintain confidentiality of all information obtained. Furthermore, I understand it is my right to request that anyone other than the healthcare provider be present.
6. During my child’s telemedicine visit, I understand that the responsibility of the telemedicine healthcare provider ends upon the termination of the video conference connection.
7. By signing this consent, I authorize my physician to release any relevant medical information, pertaining to my child’s medical condition and medical care to my insurance company or any other agent that may be responsible for paying my medical bills. I further understand and consent to being interviewed, taped, filmed, or photographed by my physician for this purpose.
8. I understand that although this is not an in-person visit, my insurance may still apply copays, deductibles or coinsurances. These will be my financial responsibility and I understand that I may pay these online at the time of service.