Introduction. Telemedicine involves the real time evaluation, diagnosis, consultation on, and treatment of health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.
Consent for Treatment. I voluntarily request Northeast Pediatric Associates, PA (A Division of Synergy Healthcare Associates, PLLC) physician(s) and such associates, residents, technical assistants and other healthcare providers as they may deem necessary (Northeast Pediatric Associates Telemedicine Providers”) to participate in my child’s medical care through the use of telemedicine.
I understand that Northeast Pediatric Associates, PA Telemedicine Providers (i) may practice in a different location than where I present for my child’s medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that Northeast Pediatric Associates Telemedicine Providers’ advice, recommendations, and/or decision may be based on factor not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my child’s medical history, condition, and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as the parent or legal guardian as to result or cure for my child.
If Northeast Pediatric Associates Telemedicine Providers determine that the telemedicine services do not adequately address my child’s medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If my child experiences an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my child’s treating physician and, in case of emergencies dial 911, or go to the nearest hospital emergency department.
Release of Information. To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my child’s medical record (including oral information) to Northeast Pediatric Associates Telemedicine Providers. All existing laws regarding privacy and security of your child’s health information and copies of your child’s medical records apply to this telemedicine health service and the audio and video information transmitted and received electronically as part of this service. Any dissemination of patient-identifiable images or information from this telemedicine interaction to researches or other entities for purposes other than your child’s treatment, payment of healthcare services your child receives, and certain necessary administrative and operational activities supporting your child’s care shall not occur without your authorization.
I consent to using telemedicine services and I understand the use and disclosure of my child’s medical records as stated above in accordance to Health Information Portability and Accountability Act (HIPAA) laws.
I have read this Informed Consent for Telemedicine Services document and I understand the risks and benefits of the telemedicine consultation and have had my concerns addressed in an understandable manner.
Northeast Pediatric Associates, P.A.
A Division of Synergy Healthcare Associates, PLLC
Main Phone: (210) - 657- 0220