I understand that I am engaging in telehealth for my child with the provider.
My child’s health care provider has explained to me how the telehealth technology will be used to connect me with a provider. Telehealth appointments may be conducted by videoconferencing, video images, still (high quality photo) images, text or by telephone conference. I understand that this appointment will not be the same as a direct patient/health care provider visit due to the fact that my child and I will not be in the same room as my health care provider. I understand that the health care provider may use devices such as a stethoscope or otoscope or other peripheral devices to assist in the examination.
I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand there can be technical failures during the visit and Grace MD Connect is not responsible for any lost information due to technical failures. I understand that my child’s health care provider or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the telehealth appointment at any time. I also understand I cannot use virtual consults to replace emergency care, routine child physicals and vaccinations, OB-Gyn care including prescription of contraception of any kind and lifestyle medications or medical management of children with complex medical issues. I agree that the healthcare provider will provide antibiotics and medications for urgent healthcare concerns only if the provider deems it medically necessary. I also understand that telehealth consults may not always deliver the outcome I desire clinically, and I am willing to participate in the service, understanding the risks. In case of medical emergency for your child - CALL 911.
I understand that my child’s healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the appointment other than my healthcare provider and specialty health care provider in order to operate the equipment. The above-mentioned people 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: (1) omit specific details of my child’s medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination room; and/or (3) terminate the telehealth appointment at any time.
I have had the alternatives to a telehealth appointment explained to me, and in choosing to participate in a telehealth appointment for my child, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the specialty health care provider or the primary care provider.
In an emergency situation, I understand that the responsibility of the telehealth specialist or provider may be to direct me to emergency medical services, such as emergency room. Or the telehealth provider may discuss with and advise my child’s local provider. The telehealth specialist’s or provider’s responsibility will end upon the termination of the telehealth connection.
I understand that billing for the telehealth consultation may occur from 1) the primary care provider and 2) telehealth provider, and 3) as a facility fee from the site from which I am presented. Billing is at the discretion of the provider. Billing procedures will be explained to me.
You authorize Grace MD Connect to invoice your credit card every month for the subscription service provided to you and you agree that if the payment cannot be authorized, then the services will cease that day. You agree you or the provider can terminate the relationship and the subscription service anytime without any binding or contract. Unless otherwise agreed to by Grace MD Connect in writing, all fees paid are non-refundable. Grace MD Connect reserves the right, without notice, to modify, change, terminate or suspend service for your subscription plan anytime.
I have also read this document and the
carefully, and understand them. I also understand the payment policy, risks, and benefits of the telehealth appointment and have had my questions and concerns answered and I hereby consent to participate in Grace MD Connect telehealth services.
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.