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This service is provided by technology (included but not limited to video, phone, text and email)
and may involve direct face to face communication.
1. I will need access to, and familiarity with, the appropriate technology in order to participate in the service
2. The information obtained and provided is through electronic means.
a. During your virtual care consultation, details of your medical history and personal health
information may be discuss with you and your health care professionals.
3. I may decline or discontinue any telehealth services at any time without jeopardizing my access
to future care,
services or benefits.
4. Telehealth which allows for great convenience in service delivery; however, there are risks in
5. The patient’s plan of care will be regularly reassessed and delivered to me using the Telehealth
with modifications to plan as needed.
7. Due to the payor source Pediatric Partners may be required to provide telehealth medical
8. Medical documents will be maintained in accordance to the HIPAA regulations.
9. The laws and professional standards that apply to in-person outpatient services also
apply to telehealth services. This document does not replace other agreements, contracts,
or documentation of informed consent.