Telehealth Consent Form

Educate. Motivate.

Telehealth Consent Form

Telehealth involves the use of electronic communications to enable our therapists to provide limited services via online video conference. Telehealth may involve any of the following:

  • Sharing of health records or videos
  • Video or audio recording
  • Live two-way audio and video
  • Two way audio and visual

Tricia H. Rogers, LLC’s has access to a variety of telehealth options:

I understand that I may expect the anticipated benefits from the use of telehealth in my/my child’s care, but that no results can be guaranteed or assured. Benefits may include:

  • Improved access to speech-language and orofacial myofunctional therapy services
  • More efficient home program management
  • Obtaining expertise of a distant specialist

As with any medical modality, there are potential risks associated with the use of telehealth. By signing this form, I understand the following:

  1. I understand that the laws that protect privacy and the confidentiality of health information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me/my child will be disclosed to researchers or other entities without my consent.
  2. I understand that in very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
  3. In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images, poor WIFI connection) to allow for appropriate decisions making by the therapist.
  4. 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, without affecting my right to future care or treatment.
  5. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction and may receive copies of this information for a reasonable fee.
  6. I understand that the video conferencing used by Tricia H. Rogers, LLC is HIPAA and GDPR compliant, but is not 100% secure.
  7. I am agreeing to telehealth visits with the knowledge and understanding that telehealth speech-language and orofacial myofunctional therapy services are not as effective as in-person services and treatment/intervention may take longer to achieve desired results.
  8. I understand that if my/my child’s therapist believes services would be improved by other interventions, I will be referred out for those services.
  9. I understand that either Tricia H. Rogers, MS-CCC or myself can terminate treatment at any time for any reason.
  10. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information released by me during the course of my sessions is confidential.
  11. Tricia H. Rogers, LLC will use private health information for billing purposes.
  12. I understand I am responsible for payment for services rendered via telehealth services as I would be for in-person services.
  13. Tricia H. Rogers, LLC will make health records available for a fee or as required by law/regulation.
  14. There are both mandatory and permissive exceptions to confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law.

I have read and understand the information provided above regarding telehealth, have discussed it with my/my child’s therapist and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth for my child/myself.

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