- Speech Therapist, Occupational Therapist, or Physical Therapist
- Therapy session provided primarily online via computer, tablet, or smartphone
- I understand that my child’s therapist intends to engage my child in a telemedicine session.
- I understand how the video conferencing technology will be used and that such sessions may not have the same effect as direct (face-to-face) therapy sessions.
- I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that the therapist or I can discontinue the telemedicine session if the videoconferencing connections are not adequate for the situation.
- I understand that my child’s healthcare information may be shared with other individuals for scheduling and billing purposes. Others may be present during the therapy session other than my child’s therapist to operate the video equipment and/or provide technical support. The above-mentioned people will maintain confidentiality of any information obtained. I further understand that I will be informed of their presence in the therapy session and thus will have the right to request the following: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non‐therapy personnel to leave the telemedicine environment, or (3) terminate the session at any time.
- Alternatives to telemedicine sessions have been explained to me and I have chosen for my child to participate in therapy via telemedicine.
- I have had a direct conversation with my child’s therapist, during which I had the opportunity to ask questions regarding this delivery option. My questions have been answered and the service delivery options have been discussed with me in a language I understand.
By signing this form, I certify:
- That I have read or had this form read and/or had this form explained to me
- That I fully understand its contents including provision of services.
- That I have been given opportunities to ask questions and receive answers to my satisfaction.