TELEHEALTH INFORMED CONSENT

1. What is Telehealth?

Telehealth (also called telemedicine) allows you to receive healthcare services remotely using technology such as video conferencing, phone calls, and secure messaging. Instead of visiting a medical office in person, you can connect with your healthcare provider from your home or another location.

2. Benefits of Telehealth

• Convenient access to pediatric care from home
• Reduced travel time and expenses
• Decreased exposure to illnesses in waiting rooms
• Flexible scheduling, including evenings and weekends
• Timely care for non-emergency concerns
• Access to specialized pediatric expertise regardless of location

3. Limitations of Telehealth

• Physical examination is limited to what can be observed via video
• Some conditions require in-person evaluation and cannot be diagnosed or treated via telehealth
• Technical difficulties (poor internet, audio/video problems) may interrupt or prevent the visit
• Certain diagnostic tests, procedures, and vaccinations cannot be performed remotely
• In some cases, I may determine that telehealth is not appropriate for your child's condition and will recommend an in-person visit

4. Your Rights

• Right to Refuse: You have the right to refuse telehealth services at any time without affecting your access to future care or any other benefits.
• Right to In-Person Care: You may request an in-person visit instead of a telehealth visit at any time.
• Right to Stop: You may stop the telehealth session at any time.
• Right to Privacy: Your telehealth session is private and confidential, subject to the same privacy protections as in-person visits.
• Right to Ask Questions: You may ask questions about any aspect of your child's care at any time.

5. Privacy and Security

I use HIPAA-compliant telehealth technology to protect your privacy. However, please be aware:

• Electronic communications carry some risk of unauthorized access despite security measures
• You should use a private, secure location for your telehealth visit
• You should use a secure, private internet connection (avoid public WiFi)
• Your medical records will be maintained according to applicable laws and my Notice of Privacy Practices

6. Prescriptions

If clinically appropriate, prescriptions may be sent electronically to your preferred pharmacy. Not all medications can be prescribed via telehealth. You are responsible for providing accurate pharmacy information and picking up prescribed medications.

7. Follow-Up Care

• I will provide instructions for follow-up care after each visit
• If your child's condition does not improve or worsens, please contact me or seek in-person care
• For ongoing conditions, I may recommend periodic in-person visits with a local healthcare provider
• I will coordinate with your child's primary care provider if you provide consent

8. Minors and Parental Consent

For patients under 18 years of age, a parent or legal guardian must:

• Provide consent for telehealth services
• Be present during the telehealth visit (or available by phone)
• Provide accurate medical history and current symptoms
• Be responsible for following treatment recommendations

9. Fees and Payment

• Acute Illness Visit: $75 (15 minutes)
• Extended Acute Visit: $145 (25 minutes)
• Guidance Visit: $225 (30 minutes)
• Extended Guidance Visit: $325 (50 minutes)
• Results Review: $45 (10 minutes)
• Follow-Up Visit: Free (same problem, within 7 days)

Payment is due at the time of service. I do not bill insurance directly. You may submit receipts to your insurance for potential reimbursement.

10. State Licensure

I am licensed to practice medicine in Maryland and Washington DC. Telehealth services can only be provided when the patient is physically located in one of these states at the time of the visit:

Maryland and Washington DC