Telehealth Patient Consent Form

I [Entered Child's Name Above] agree to receive this health care service. I understand that the health care provider, Dr. Yeshlur, is located in another location, Sweetwater Pediatrics 1101 Gateway Blvd Rock Springs WY. A Telehealth service means that my visit with a practitioner at the distance site will happen by using special audiovisual equipment. This consent is valid for 1 year for follow-up telehealth services with the health care provider.

I also understand that:

• I can decline the telehealth service at any time without affecting my right to future care or treatment, and any program benefits to which I would otherwise be entitled cannot be taken away
• I may have to travel to see a health care provider in-person if I decline telehealth service.
• The same confidentiality protections that apply to my other medical care also apply to the telehealth service.
• I will have access to all medical information resulting from the telehealth service as provided by law
• The information from the telehealth service (images that can be identified as mine or other medical information from the telehealth service) cannot be released to researchers or anyone else without my additional written consent.
• I may see an appropriately trained staff person or employee in-person immediately after the telehealth service if an urgent need arises OR I will be told ahead of time that this is not available.

I have read this document carefully and my questions have been answered to my satisfaction.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

OR

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Telehealth Consent:

Facility Name: Sweetwater Pediatrics
Facility Address: 1101 Gateway Blvd Rock Springs Wy