Saugatuck Pediatrics LLC Telehealth Patient Consent Form
A Telehealth service means that my visit with my doctor at Saugatuck Pediatrics has determined that a telehealth visit is appropriate and will happen by using special audiovisual equipment. This consent is valid for one year for follow-up Telehealth services with the health care provider.
I also understand that:
- I can decline the Telehealth service at any time without affecting my right to future care or treatment, and any program benefits to which I would otherwise be entitled cannot be taken away.
- I may have to travel to see a health care practitioner in-person if I decline the Telehealth Service.
- If I decline the Telehealth service, the other options/alternatives available for me, including in-person services are available in our office.
- The same confidentially protections that apply to my other medical care also apply to the Telehealth service.
- I will have access to all medical information resulting from the Telehealth service as provided by law.
- The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service cannot be released to anyone else without my additional written consent.
- I will be informed of all people who will be present at all sites during my Telehealth service.
- I agree to an “in-person” visit if the doctor decides is necessary.
While many states have ‘pay parity’ for Telehealth (visits covered as if delivered in the office), Connecticut currently does not require insurers to cover such care. Until that time arrives, our virtual visits may not be covered, and it is your responsibility to determine whether your insurance will pay for these visits. Charges for telehealth visits are identical to in office care, meaning they are based on either the complexity of the visit or time spent on the visit. If insurance declines the cost of the visit, your on-file credit card will be charged.
By signing this consent, I am also giving permission to release information to my insurance company or third party payer.
I have read this document carefully, and my questions have been answered to my satisfaction.