Healthcare Child Telehealth Consent Form

Healthcare Child Telehealth Consent Form

Patient Information (Child)

Patient Name:

Parent / Legal Guardian Information

Insurance Information

Medical History (Relevant)

Telehealth Services — Description and Consent

Description: The provider will deliver clinical evaluation, counseling, and related health care services via telehealth technologies, which may include live video, audio-only telephone, and secure messaging. The parent/guardian authorizes telehealth services for the child named above.

Telehealth Modality Consent:

I consent to real-time interactive video visits.

I consent to audio-only telephone visits when video is unavailable or clinically appropriate.

I consent to secure messaging or email for brief clinical communications and appointment management.

Risks, Benefits, and Alternatives

Benefits: Telehealth can increase access to care, reduce travel, and allow timely clinical assessment. The provider believes that telehealth is an acceptable option for the child’s care at this time.

Risks: Potential risks include technical failure, incomplete assessment due to lack of physical examination, breaches of confidentiality despite reasonable safeguards, and limits on emergency response. The parent/guardian understands these risks.

Alternatives: The parent/guardian may decline telehealth and request an in-person visit, delayed care, or referral to another provider. Declining telehealth will not affect the child's right to future care.

Privacy, Security and Recording

The provider will use platforms and procedures designed to protect patient privacy and data security; however, no transmission is completely secure. The parent/guardian acknowledges that there is some risk of interception or unauthorized access.

Recording Consent: I authorize the recording of telehealth sessions where required for clinical care or documentation.

I consent to audio and/or video recording of telehealth sessions.

Information Sharing: I authorize the provider to share telehealth visit information with other treating providers, schools, or health entities as necessary for treatment and coordination of care.

I authorize sharing with school personnel as needed.

I authorize sharing with other health care providers for continuity of care.

Technical Requirements and Participation

The parent/guardian agrees to ensure an appropriate private setting, working audio/video equipment, and a reliable internet or telephone connection. It is the parent's responsibility to supervise the child during the telehealth visit and to provide accurate clinical information.

If telehealth is interrupted and cannot be restored, the provider will attempt to reconnect or arrange an alternative such as a telephone visit or in-person care when clinically indicated.

Emergency Plan

Telehealth is not appropriate for medical emergencies. In an emergency, call local emergency services. The parent/guardian authorizes the provider to take appropriate action, including contacting emergency services or the emergency contact listed above if the provider believes the child is at imminent risk of harm.

Billing and Consent Duration

Telehealth services will be billed in accordance with the provider’s normal fee schedule and applicable insurance coverage. The parent/guardian remains responsible for co-payments, deductibles, and any charges not covered by insurance.

Acknowledgment and Certification

By signing below, I certify that I am the parent or legal guardian of the patient named above and that I am authorized to consent to telehealth services on behalf of the child. I have read and understand the information in this form, I have had an opportunity to ask questions and have received satisfactory answers, and I voluntarily consent to telehealth services as described.

I understand that I may revoke this consent in writing at any time, except to the extent that actions have already been taken in reliance on it. Revocation will not affect records created or disclosures made while consent was in effect.

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