M.T. Curry Inc - Publicforms

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12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

Telehealth Agreement

TELEHEALTH AGREEMENT & CONSENT FORM

Patient Name *

First & Last

Date of Birth *

Introduction to Telehealth

Telehealth allows healthcare providers to share patient information long-distance for the purpose of enhancing patient care using real-time electronic communications. The use of Telehealth services may help limit the spread of communicable diseases, including the Coronavirus (COVID-19).

During your exam Protected Health Information (PHI), including Lab &/or Test Results, Medications and treatment plans may be discussed using Live- two-way Audio and Video, and Output data from health devices and sound and video files. The information gathered using Telehealth may be used for diagnosis, treatment, follow-up and/or education.

Electronic systems used will feature network and software security practices to protect the confidentiality of patient identification and imaging data and will include processes to safeguard patient data and to guarantee its integrity against intentional or unintentional corruption.

Terms of Use

By signing below, I indicate my understanding of the following:

1. I understand that the laws that protect my privacy and the confidentiality of my health information also apply to telehealth, and that none of my information acquired through the use of telehealth will be disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth during my care at any time, without affecting my right to future care or treatment.

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

4. I understand that there are risks associated with Telemedicine to include: in rare cases, the insufficient transmission of data (e.g. poor resolution of images, poor audio) to allow for suitable decision making by the providers or delays in evaluation and treatment due to defects or failures of technical equipment. In exceedingly rare instances, security protocols could fail, causing a breach of privacy of personal health information.

5. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

6. I understand that I have the right to inspect all information obtained and recorded during a telehealth interaction and may request copies of this information at any time for a reasonable fee.

7. I understand that a variety of alternative methods of health care may be available to me, to include in office and drive up appointments (for COVID-19 Exposure Only) and that I may choose one or more of these treatment options at any time.

8. I understand that the use of Telehealth is not an appropriate mode of treatment for all appointment types and that patient suitability for telehealth services is at the discretion of the healthcare provider.

9. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

10. I understand that it is my duty to maintain updated demographic records with M. T. Curry Pediatrics to ensure that I can be contacted for Telehealth Services.

11. I understand that I will be contacted a maximum of 3 times at the time of my appointment to begin the exam. If there is no answer M. T. Curry Pediatrics will assume that I do not wish to keep my appointment.

12. I understand that M. T. Curry Pediatrics No-Show and Cancellation Policies apply to Telehealth services and should I not be able to keep my scheduled appointment I must provide 24 hours? notice to avoid fees.

13. I understand that if I fail to answer the call for my appointment on more than one occasion that I will no longer qualify for Telehealth Services.

14. I understand that my current insurance may not cover the additional fees of the Telehealth services and I may be responsible for any fee that my insurance company does not cover.

I have read and understand the information provided above regarding Telehealth. I have had the opportunity to discuss this with designated personnel, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telehealth in my care. *

I Agree

Patient/Parent or Guardian Signature *

First & Last Name

Today's Date *

* Required field