Informed Consent for Telehealth Medical and Tele-Behavioral Services

Last modified: March 2024

INFORMED CONSENT FOR TELEHEALTH AND TELE-BEHAVIORAL SERVICES- Clarity Pediatrics Medical Group

DO NOT USE THIS SERVICE IF YOUR CHILD MAY BE EXPERIENCING A MEDICAL EMERGENCY. In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

We are pleased you have chosen Luis Alesandro Larrazabal Martinez, M.D., P.C. d/b/a Clarity Pediatrics Medical Group (“Clarity Pediatrics Medical Group”), for your child’s medical and behavioral health needs. This document is intended to inform you of what you can expect of your child’s clinician in terms of his or her credentials and in connection with your treatment via telehealth. After you have carefully read this document and had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

YOUR CHILD’S CLINICIAN’S CREDENTIALS. Your child’s medical and/or behavioral health clinician’s credentials were made available to you and your child before scheduling an appointment. If you have any questions about these credentials, please direct them to your child's clinician. For those states that require it, you can find an explanation of the levels of regulation applicable to mental health clinicians and medical providers under the STATE REGULATIONS section of this document.

IMPORTANT INFORMATION REGARDING YOUR CHILD’S TREATMENT BY TELE-BEHAVIORAL AND TELEHEALTH MEDICAL PROVIDERS, INCLUDING POTENTIAL RISKS AND BENEFITS OF TELEHEALTH TECHNOLOGIES. Clarity Pediatrics Medical Group offers individual, scheduled counseling sessions by means of tele-behavioral and telehealth (collectively, “telehealth technologies”). This fancy term simply means treatment by various providers of medical and mental health via telecommunications technology. Our clinicians may include skilled and experienced Psychologists, Physicians, Licensed Professional Counselors, Licensed Clinical Social Workers, Marriage and Family Therapists, and equivalent licensed professionals. They each use a collaborative treatment process wherein they work with you and your child on identified goals for overall improvement and changes you deem important or necessary to improve the quality of your child’s life. The services provided may also include chart review, remote prescribing, appointment scheduling, refill reminders, health information sharing, and non-clinical services, such as patient education. The electronic communication systems we use 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.

Generally speaking, medical and behavioral health visits conducted via telehealth technologies offer benefits such as improved access to care by enabling patients to remain in their local site (e.g., home or work) while their clinician consults and/or obtains test results at distant/other sites, efficient mental health or other appropriate medical evaluation and management, and the expertise of specialists that patients otherwise might not have.There are potential risks associated with telehealth technologies which include, but may not be limited to: the clinician may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient; delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; security protocols could fail, causing a breach of privacy of personal medical information; lack of access to complete medical records, which could result in adverse drug interactions or allergic reactions or other judgment errors in rare cases; and, it may become clear that telehealth visits, are not an appropriate treatment format given a patient’s presenting symptoms or level of functioning, resulting in a recommendation that the patient obtain additional in-person care with their primary care doctor.

At times, your child’s clinician may seek supervision or consultation with other Clarity Pediatrics Medical Group clinicians regarding your child’s treatment, to enhance the services being provided to your child given the multiple perspectives, experiences, and treatment philosophies. All team members are ethically and legally bound to maintain your child’s privacy and confidentiality in this scenario and none of your child’s personal information will be shared or disclosed with any other individual without your consent. Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult; court order and/or subpoena; permission from the client or guardian (i.e. voluntary release signed by the client or guardian); during supervisory consultations; diagnosis and dates of service shared with an insurance company to collect payments; information released as outlined in Clarity Pediatrics Medical Group’s Notice of Privacy Practices and Privacy Policy; and as otherwise required by law.

TREATMENT AND CONFIDENTIALITY OF MINORS. In accordance with state laws, consent for treatment of a minor can only be authorized by a current legal guardian for the minor. If the parents of a minor are separated, treatment is provided to the minor only with the written consent of both parents. If the parents of the minor are divorced, consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court   of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and clinician in order to maintain the rapport established between the minor  and clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consulted about the disclosure and encouraged to share the information with the parent first    in order to establish better communications within the family structure.

SCHEDULING AND CANCELLATIONS.  Our telehealth services are available 10 hours a day, 5 days a week. We will make all reasonable efforts to respond to your messages within 2 business days.

MEDICATION MANAGEMENT. You acknowledge that the American Academy of Pediatrics recommends Behavioral Parent Training (BPT), school-based interventions, and FDA-approved medication for school-age children with ADHD. If medication is of interest to your family, or a part of your current care plan, the Clarity Pediatric Medical Group providers can conduct a medication intake session. All medication management services will be provided at the professional discretion of the Clarity Medical Group Provider. Medication is not guaranteed as part of the services provided. Any prescription orders will be sent to your family’s pharmacy of choice. You may update your pharmacy selection at any time, as needed.

FEES AND BILLING ARRANGEMENTS.  Prices are subject to change. You are required to pay all fees for your child’s telehealth services upfront at the time of service; however, you are not obligated to pay any fees for which another party (e.g., your employer or health plan) pays on your child’s behalf. If you believe any of the fees you have been charged are incorrect, you must immediately contact us in writing regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within fifteen (15) calendar days after the charge, that you believe the charge is inaccurate (setting forth an explanation of why).

You also hereby authorize the direct payment of all insurance and plan benefits, including Medicare, Medicaid and/or Tricare, otherwise payable to or on your child’s behalf for services rendered, to Clarity Pediatrics Medical Group. If you receive payment directly from your insurance company or third-party payer, you agree to immediately forward all healthcare payments that you receive for services provided to you.

‍By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:

1. You hereby consent to your child receiving Clarity Pediatrics Medical Group’s services via telehealth technologies. You understand that Clarity Pediatrics Medical Group and its providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your child’s primary care doctor. You also understand it is up to the Clarity Pediatrics Medical Group provider to determine whether or not your child’s specific clinical needs are appropriate for a telehealth encounter.
2. You have been given an opportunity to select a provider from Clarity Pediatrics Medical Group prior to the consult, including a review of the provider’s credentials.
3. You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Clarity Pediatrics Medical Group will take steps to make sure that your child’s health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your child’s personal medical information to other health practitioners who may be located in other areas, including out of state.
4. You understand there is a risk of technical failures during the telehealth encounter beyond the control of Clarity Pediatrics Medical Group. You agree to hold harmless Clarity Pediatrics Medical Group for delays in evaluation or for information lost due to such technical failures.
5. You understand that you have the right to withhold or withdraw your consent to the use of telehealth technologies in the course of your child's care at any time, without affecting your child’s right to future care or treatment. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if your child is experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that the Clarity Pediatrics Medical Group providers are not able to connect you directly to any local emergency services.  
6. You understand that alternatives to telehealth consultations, such as in-person services are available to you and your child, and in choosing to participate in a telehealth consultation, you understand that some parts of the services involving tests may be conducted by individuals at your child’s location, or at a testing facility, at the direction of the Clarity Pediatrics Medical Group provider (e.g., labs or bloodwork).
7. You understand that your child may expect the anticipated benefits from the use of telehealth technologies in your care, but that no results can be guaranteed or assured.
8. You understand that your child’s healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Clarity Pediatrics Medical Group provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the consultation and thus will have the right to request the following: (a) omit specific details of your child’s medical history/examination that are personally sensitive to your child; (b) ask non-medical personnel to leave the telehealth examination; and/or (c) terminate the consultation at any time.  
9. You understand that your child will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.
10. You understand that if your child participates in a consultation, that you have the right to request a copy of your child’s medical or behavioral health records which will be provided to you at reasonable cost of preparation, shipping and delivery.
11. You have read and you understand the disclosures set forth next to the state in which you and your child are located at the time of the telehealth encounter, as set forth below:
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STATE REGULATIONS.

You have read this document carefully, and understand the risks and benefits of the telehealth services and have had your questions regarding the services explained and you hereby give your informed consent to participate in a telehealth consultation under the terms described herein.

By checking the Box for this "INFORMED CONSENT FOR TELEHEALTH SERVICES" you hereby state that you have read, understood, and agree to the terms of this document.