Telepractice Policy

Video conferencing technology will be used to deliver therapy and it will not be the same as a direct face to face visit because I will not be in the same room as my therapist. Tele health/Telemedicine known as telepractice involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Telepractice requires transmission, via Internet or tele-communication device, of health information, which may include:

• Progress reports, assessments, or other intervention-related documents
• Bio-physiological data transmitted electronically
• Videos, pictures, text messages, audio and any digital form of data

There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my therapist or I can discontinue the telepractice session if it is felt that the videoconferencing connections are not adequate for the situation. BOLD Center will attempt to reschedule the session when possible.

Risk

As with any Internet-based communication, there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

My healthcare information may be shared with other individuals for scheduling and billing purposes. Another person may also be present during the consultation other than my therapist to assist in operating the video equipment or graduate student learning. These people will all maintain confidentiality of the information obtained. I will be informed of their presence and thus will have the right to request the following: (1) ask non-medical personnel to leave the telepractice therapy room; and or (2) terminate the consultation at any time.

Privacy

The laws that protect the privacy and confidentiality of health and care information also apply to telepractice. Information obtained during this session that identifies me or my child will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations. By agreeing to use the telepractice services, I am consenting to BOLD Center sharing of my protected health information with certain third parties as more fully described in BOLD Pediatrics’ Privacy Policy. I understand, agree, and expressly consent to BOLD Pediatric obtaining, using, storing, and disseminating to necessary third parties, information about me or my child, including my image, as necessary to provide the Tele health/telemedicine services.

Some parts of the Tele health session may require physical handling or physical assistance and may be conducted by another person at my location, at the direction of the therapist. This will likely be a parent or caregiver. I understand that it may also be necessary to participate in periodic face to face service delivery on site at BOLD Pediatric Therapy Center to ensure continued appropriateness of care. I agree to periodic on-site sessions as provider license requires or need for evaluation.

I have the right to withhold or withdraw consent to the use of telepractice at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telepractice, it will not affect any future services or care benefits to which I am entitled.