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Dayton Children's Hospital Consent for Telehealth Services


You have the right to make your own decisions about your/your child’s health care. This form will help you understand the telehealth services you/your child is expected to receive.
•    Please read the form and ask about any part you do not understand.
•    Be sure your questions are answered before you agree to this form.
•    When you agree to this form, you are giving Dayton Children’s permission to provide telehealth services to you/your child.


Nature of Telehealth Consult: It has been explained to me/my child how the video conferencing technology will be used to conduct a telehealth encounter. I understand this encounter will not be the same as an in-person visit due to the fact that I/my child will not be in the same room as the healthcare provider. During the telehealth consultation:
•    Details of my/my child’s medical history, examinations, x-rays, and tests may be discussed, including with other health professionals, through the use of interactive video, audio, and telecommunication technology.
•    A physical examination may take place.
•    Video, audio and/or photo recordings may be taken of me/my child during the examination, and may be used for diagnosis, therapy, follow-up and/or education.

Possible Risks: I understand that:
•    Despite reasonable efforts on the part of my healthcare provider, there are potential risks to telehealth technology, including interruptions, unauthorized access and technical difficulties.
•    Communication with the provider may be delayed, distorted or inaccurate due to technology-related issues such as poor connectivity or image or sound quality.
•    It is important to use a secure network; access through a public access computer or on a shared network that is also accessed by employers, friends, or others is not secure and should be avoided.

Right to Discontinue Services: I understand that:
•    I have the right to refuse or stop participation in telehealth services at any time and request alternate services such as an in-person appointment. Such refusal will not affect my/my child’s right to future care or treatment, and will not risk loss or withdrawal of any benefits to which I/my child would otherwise be entitled
•    Either the health care provider or I can discontinue the telehealth encounter if it is felt that the connection is not adequate for the situation.
•    Equivalent in-person services might not be available at the same location or time as telehealth services.

Medical Emergencies: If an emergency occurs during a telehealth encounter at a hospital or clinic, health care personnel at my/my child’s location will manage the emergency. If an emergency occurs when I am at a non-health-care site (e.g., at home), I should call 911 and stay on the video connection (if applicable) until help arrives.

Transmission of images: I authorize the provider to use video streaming services and to take photographs and/or recordings of me/my child during the telehealth encounter. Where medically necessary, such images might involve partial nudity. I understand that streaming services, photographs, and/or recordings will be kept confidential, and will be used only to provide health care services to me/my child. Any photograph and/or recording will be maintained as a confidential medical record, consistent with federal and state law. I understand that not all telehealth encounters are recorded.

Confidentiality: I understand that reasonable and appropriate efforts have been made to eliminate confidentiality risks associated with the telehealth consultation. All existing laws regarding confidentiality, medical information, and copies of medical records existing under federal and state law apply to information disclosed during this telehealth encounter.

I understand it may be necessary for others to be present during the telehealth encounter other than my/my child’s healthcare provider in order to operate the video equipment. These individuals are bound to maintain confidentiality of all information obtained. I further understand that I have the right to request the following when nonmedical personnel are present to: (1) omit specific details of my/my child’s medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the examination room; and/or (3) terminate the telehealth encounter at any time.

By agreeing to this form, I certify:
•    That I have read or had this form read and/or had this form explained to me.
•    That I fully understand its contents including the risks and benefits of using telehealth.
•    That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
•    I hereby give informed consent for the use of telehealth in my/my child’s medical care