Consent to Telehealth

Last updated: April 6, 2018

I hereby consent and authorize healthcare professionals affiliated with Blueberry Pediatrics I engage through the use of the website located at blueberrypediatrics.com and other related websites and mobile applications (collectively, the “Site”) to provide telehealth services.

I certify that a healthcare professional has explained the nature, benefits and risks of any services I receive from any healthcare professional I engage through the Site. I have been given the opportunity to ask questions about any concerns regarding the services I will receive from any healthcare professional I engage through the Site. I also understand that the Site is not intended to be used as a hotline. If I believe I am having an emergency, I will dial 911, go to the nearest emergency room, or contact the appropriate healthcare personnel.

Introduction

Telehealth involves the use of audio, video or other electronic communications allowing me to interact with my healthcare professional for the purpose of diagnosis and treatment. During my telehealth consultation, details of my medical history and personal health information may be discussed with me through the use of interactive video, audio or other telecommunications technology.

Electronic systems used will incorporate network and software security protocols to protect the privacy and security of my health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

Anticipated Benefits

  • Improved access to health care by enabling an individual to remain in his/her location while the healthcare professional may provide care from a distant site.

  • More efficient evaluation and management.

  • Obtaining expertise of a distant specialist.

Possible Risks

  • Delays in evaluation/treatment could occur due to deficiencies or failures of the electronic equipment, including interruptions, unauthorized access and technical difficulties.

  • In rare instances, security protocols could fail, causing a breach of privacy of personal health information.

I Understand the Following:

  1. I understand that I may expect the anticipated benefits from the use of telehealth but that no results can be guaranteed.

  2. I understand that Blueberry Pediatrics uses telehealth appointments, and that I am choosing to use Blueberry Pediatrics at my own discretion.

  3. I understand that I may be directed to use devices such as a thermometer, pulse oximeter, at-home tests, or other peripheral devices to assist in the provision of telehealth.

  4. I understand that a variety of alternative methods of health care may be available, and that I may choose one or more of these at any time. My healthcare professional has explained the alternative to my satisfaction.

  5. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time.

  6. Others may be present during the appointment other than my healthcare professional.  These otherassociates will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence during the consultation and thus will have the right to request the following: (a) omit specific details of my medical history/physical examination that are personally sensitive to me; (b) ask non-medical personnel to leave the telehealth examination room; and/or (c) terminate the telehealth appointment at any time.

  7. I understand that it is my duty to inform my usual healthcare professionals of electronic interactions regarding my care that I may have with other health care professionals.

  8. I understand that telehealth may involve electronic communication of my personal medical information to other practitioners who may be located in other areas, including out of state.

I have read and understand the information provided above regarding telehealth, and have discussed it with my healthcare professional, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth under the terms described herein.