Georgia Pediatric Therapy – Telehealth Member Consent Form

At Georgia Pediatric Therapy, we are committed to providing high-quality care for your child, no matter where you are. Telehealth allows us to connect with you and your child virtually, offering convenient access to our expert therapists from the comfort of your home.

Before we begin, it’s important to ensure that you fully understand the details of our telehealth services, your rights as a participant, and how your information will be handled. Please carefully read and complete this consent form to confirm your agreement and readiness to proceed with telehealth sessions.

If you have any questions or concerns, don’t hesitate to contact us at 404-709-0840, we’re here to help!

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Telehealth Member Consent Form

Patient Name:

Date of Birth:

1. PURPOSE: The purpose of this form is to obtain your consent to participate in a telehealth consultation in connection with the following procedure(s) and/or service(s): Speech, Occupational, and/or Physical Therapy.
2. NATURE OF TELEHEALTH CONSULTATION: During the telehealth consultation, details of your medical history, examinations, x-rays, and tests will be discussed with other health professionals through interactive video, audio, and telecommunication technology.
3. Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.
4. A physical examination may take place.
5. A non-medical technician may be present in the telehealth studio to assist with the video transmission.
6. Video, audio, and/or photo recordings may be made during the procedure(s) or service(s).
7. MEDICAL INFORMATION & RECORDS: All laws regarding your access to medical information and copies of your medical records apply to this telehealth consultation. Please note that not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information related to this telehealth interaction to researchers or other entities will not occur without your consent.
8. CONFIDENTIALITY: Reasonable and appropriate efforts have been made to mitigate confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this consultation.
9. RIGHTS: You may withhold or withdraw consent to the telehealth consultation 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.
10. DISPUTES: You agree that any dispute arising from the telehealth consultation will be resolved in Georgia, and that Georgia law shall apply to all disputes.
11. RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences, and benefits of telehealth. Your healthcare practitioner has discussed this information with you. You have had the opportunity to ask questions, and all your questions have been answered. You understand the written information provided above and agree to participate in the telehealth consultation for the procedure(s) described.

Person Completing the Form:

Phone:

Relationship:

Email:

Telehealth Member Consent:

I agree to participate in a telehealth consultation for the procedure(s) described above.

Signature:

Telehealth Member Consent Form

Welcome to Our Telehealth Services

Telehealth Member Consent Form

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