Telehealth Member Consent Form

Telehealth Member Consent Form

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  • 1. Purpose: The purpose of this form is to obtain your consent to participate in a telehealth consultation in connection with the following procedure(s) and/of service(s): Articulation/phonology evaluation and treatment (92507, 92522), language evaluation and treatment ( 92523, 92507), Fluency evaluation and treatment (92521, 92507), Voice evaluation and treatment (92524, 92507), cognitive/ language evaluation and treatment (92523, 97532), and swallowing evaluation and treatment(92610, 92526).

    2. Nature of Telehealth Consult: During the telehealth consultation:
       a. Patient will receive the same therapy through a live video connection, over the internet as in a face to face visit.
       b. If patient is a minor a parent or caregiver must be present during the session.
       c. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s).

    3. Medical information & Records: All existing laws regarding your access to medial information and copies of your medical records apply to this telehealth consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient- identifiable images or information for this telehealth interaction to researchers or other entities shall not occur without your consent.

    4. Confidentially: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telehealth consultation.

    5. Rights: You may withhold or withdraw consent to the telehealth consultation at any time without affection your right to future care of treatment risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

    6. Disputes: You agree that any disputes arriving from the telehealth consult will be resolved in Georgia, and that Georgia law shall apply to all disputes.

    7. Risks, Consequences & Benefits: You have been advised of all the potential risks, consequences and benefits of telehealth. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telehealth consultation. All your questions have been answered, and you understand the written information provided above.

    I agree to participate in a telehealth consultation for the procedure(s) described above.

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