TELEHEALTH SERVICES CONSENT

Telehealth (also referred to as a "virtual visit") allows the school's telehealth staff to consult with PanCare of Florida, Inc. (PanCare) medical professionals through the use of telecommunication technology.

By signing this form, I understand the following:

1. I give my consent for my child to be enrolled in the school's Telehealth Program and that PanCare and its providers can access my child's personal health information, if needed.
2. I understand that I have the right to withhold/withdraw my consent to the use of telehealth at any time without affecting my child's right to future care or treatment. Furthermore, I understand that alternative methods of medical/health care may be available, including face-to-face interaction, and that I may choose another alternative at any time.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth interaction and may receive copies of this information in accordance with Florida law.
4. I understand that the information disclosed by my child during the course of my child's treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and vulnerable adult abuse.

Electronic communication allows, at a minimum, the use of audio and video equipment for two-way, encrypted, real-time interactive communication between the patient (at the school/originating site) and the healthcare provider (at the remote/distant site). Providers may include primary care practitioners, physician assistants, nurse practitioners, specialists and/or subspecialists, and therapists.

I understand that as with any medical procedure, there are expected benefits and potential risks associated with the use of telehealth that I need to be aware may exist.

Expected Benefits include the following:

• Improved access to care by enabling a patient to remain at a remote site while receiving professional care from a healthcare provider.
• More efficient medical and health evaluation and management
• Earlier diagnosis/treatment.

Possible Risks include, but are not limited to:

• As with any healthcare providers, despite reasonable safeguarding efforts, the transmission of my child's medical information could be disrupted or distorted by technical failures resulting in delays in evaluation.
• As with any healthcare providers, telehealth-based services may not be as complete as the parent would prefer. I understand that if my child's telehealth provider believes that my child will be better served by another form of services (e.g., face-to-face services) my child will be referred to another provider and it is my responsibility to ensure that referral instructions are followed timely.
• As with any healthcare providers, in rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate decision making by the telehealth healthcare provider.
• As with any healthcare providers, in rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
• As with any healthcare providers, in rare cases, a lack of access to complete and/or accurate medical records or information may result in adverse drug reactions, allergic reaction, or other judgment error.

I have read and understand the information provided above regarding telehealth and all questions have been answered to my satisfaction. I understand any cause of action arising out of this service must do so exclusively in Florida and I knowingly waive my right to access any other legal forum.

I provide my informed consent for my child to receive mental health counseling services if referred by school personnel, to bill my insurance for services provided, for PanCare of Florida providers to send prescriptions for my child to the pharmacy of my choosing when needed, and to provide medical/health care for my child including the use of telehealth.

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.