By signing this form, I designate that I understand and I agree with the following:
Can I use telehealth for any concern? Telehealth is available for a limited number of concerns. These concerns have been determined based on your child’s healthcare providers’ ability to diagnose and treat your child accurately with your child’s best health interest in mind. Our staff has been extensively educated as to what concerns may be scheduled for telehealth. These guidelines may not be changed.
Your child must also have had a well child check in the last 13 months if over the age of 3 in order to be eligible for telehealth. For children under the age of 3, your child must be up to date with routine well checks according to the prescribed schedule in order to be eligible for telehealth.
Where will my child’s provider be during my child’s telehealth visit? My child’s provider will be at 130 Enterprise Parkway during my child’s visit. My child’s provider will be in a private location in the office.
Where do my child and I need to be during my child’s visit? Both you (or an adult designated by you in writing) and your child must be present and on the video screen during the visit. You must be in any quiet, private location during your child’s visit. You may NOT be operating a motor vehicle during the visit; but you may be in a parked vehicle. If you are on vacation, it is acceptable for you to be seen via telehealth from a different state. However, recurrent visits cannot be provided in a different state.
When is telehealth available? Telehealth is available during designated office hours. Telehealth is NOT available after hours or on weekends or holidays.
Will my insurance pay for telehealth? We will not know if your insurance pays for telehealth until the claim is filed. You will be charged your copay at the regular rate and the claim will be filed. If your insurance does not cover telehealth visits, you will be responsible for the full cost of the visit.
Am I responsible for payment if my technology fails? If your internet connection is not strong enough to support a visit, or your technology otherwise fails, or you do not answer the call at the time of the visit, we will reschedule your appointment either via telehealth or in-person as soon as there is an available appointment. However, whether or not the appointment is rescheduled, you will be responsible for any charges associated with the visit.
If there is an internet or server outage at Storybook Pediatrics, you can choose to be rescheduled via telemedicine at the next available appointment or scheduled for an in-office visit. You will not be responsible for charges if the provider’s technology fails.
Are you able to diagnose an ear infection via telehealth? If you are in possession of a video otoscope and are able to place it in your child’s ear canal such that a provider is able to visualize your child’s ear drum in real time, we may do a telehealth visit for suspected ear infections. If you do not have a video otoscope and would like to purchase one, we strongly recommend this one:
https://a.co/d/6O8BuM5
If you have or obtain a different brand or model of video otoscope, we will make every effort to complete the exam with said instrument.
Due to limitations of telehealth, by signing below you denote understanding that you may be requested to schedule an in-office visit after an attempted telehealth and assume all associated costs of each visit in the following circumstances:
- Your instrument is not functioning or of the quality to allow the provider to adequately assess your child’s ear drum
- Your child's ear drum is obstructed from view by wax
- Your child has a foreign body in his/her ear
- Your child cannot be still or you cannot hold your child still in such a way as to accurately visualize your child’s ear drum
- Your child’s ear drum cannot be visualized in real time at the time of the telehealth visit for any reason
You assume all responsibility for the safety of your child during this visit. An otoscope can puncture a child’s ear drum if not used properly. You are assuming all risk associated with damage to your child’s ear drum or any other body part during a telehealth visit.
You understand that a telehealth visit cannot be utilized to diagnose any other illnesses associated with an ear infection, including but not limited to sinusitis, bronchiolitis, bronchitis, or pneumonia.
Telehealth involves the use of electronic communication to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care.
Providers may include physicians and pediatric nurse practitioners, nurses and medical assistants who are part of my child’s clinical care team. In addition to myself and the
members of my clinical care team, my child’s parents or legal guardians, or other caregivers
designated in writing by my child’s parents or legal guardian may join in and participate on the
telehealth service; and I agree to share my child’s personal information with such entities.
The information may used for diagnosis, therapy, followup, and/or education.
Telehealth requires transmission, via the internet, of health information which may include:
Progress reports, assessments, or other intervention-related documents
Videos, pictures, audio, and any digital form of data
The laws that protect the privacy and confidentiality of health care information also apply to telehealth. Information obtained during telehealth that identifies my child will not be given to anyone without my consent except for the purposes of treatment, education billing, and
healthcare operations.
I understand, agree, and expressly consent to Storybook Pediatrics obtaining, using, storing, and disseminating to necessary third parties, information about my child, including my child’s image, as necessary to provide the telehealth services.
As with any internet-based communication, I understand there is a risk of a security breach.
Electronic systems used will incorporated network and software security protocols to protect the confidentiality of patient identification and health information and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Individuals other than my clinical care team or consulting providers may also be present and have access to my child’s information for the telehealth session. This is so that they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.
Telehealth sessions many not always be possible. Disruptions of signals or problems with the internet’s infrastructure may cause broadcast and reception problems (i.e. poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between the clinician, patient, and parent.
I hereby release and hold harmless Storybook Pediatrics and all members of my care team from any loss of data or information due to technical failure associated with the telehealth service.
I understand and agree that the health information I provide at the time of my child’s telehealth service may be the only source of health information used by the medical professionals during the course of my child’s evaluation and treatment at the time of my child’s telehealth visit and that such professionals may not have access to my child’s full medical record or information.
I understand that I will be given information about tests and treatment, including the benefits, risks and alternative choices for my child’s medical care through the telehealth visit. I have the right to withhold or withdraw consent to the use of telehealth services at any time and request an in person visit.
I understand that charges for a telehealth visit will not be removed once the visit has begun. Applicable no-show charges will apply if you and your child are not available for your child’s visit during the scheduled time-window.
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Signature of Patient’s Legal Representative Date
(Must be a parent or legal guardian)
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Printed Name of Patient’s Legal Representative Relationship to Patient
