Telehealth services involve the use of secure interactive videoconferencing equipment (Let’s Talk Interactive) that enable health care providers to deliver health care services to patients when located at different sites.
1.) I understand that the same standard of care applies to a telehealth visit as applies to an in-person visit.
2.) I understand that my child will not be physically in the same room as my provider. I will be notified of and my consent obtained for anyone other than the provider present in the room.
3.) I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
- If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that the provider may discontinue the visit and make other arrangements to complete the visit.
4.) I understand that I have the right to refuse my child’s participation or decide to stop participating in a telemedicine visit and that my refusal will be documented in my child’s medical record. I also understand that my refusal will not affect my child’s right to future care or treatment.
5.) I understand that the laws that protect privacy and the confidentiality of health care information apply to telehealth services.
6.) I understand that my child’s health care information may be shared with other individuals for scheduling and billing purposes.
- I understand that my insurance carrier will have access to my child’s medical records for quality review/audit.
- I understand that the guarantor will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my child’s telehealth visit.
- I understand that health plan payment policies for telehealth visits may be different from policies for in-person visits.
7.) I understand that this document will become part of my child’s medical record
By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternative to telehealth visits shared with me in a language I understand; and (3) am located in the state of West Virginia and will be in West Virginia during my telehealth visit(s).