Telehealth Policy

Thrive Pediatrics, LLC INFORMED CONSENT FOR TELEMEDICINE SERVICES AND TREATMENT

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I, ________________________________________ (“Patient”) understand how a telemedicine
encounter is different from an in-person consultation due to the fact that I will not be in the same
room as my provider, and how this can improve my access to care, including limiting the spread
of communicable diseases. At the same time, I also understand that telemedicine has certain
risks including a limited physical exam and time constraints. I understand these risks and
limitations and will have the opportunity to discuss these with my doctor at the time of my
consultation.

I also understand that there may be interruptions, unauthorized access and technical difficulties
associated with my telemedicine encounter. Because of these reasons and the fact that a
telemedicine consultation may not be appropriate to address my medical situation, my provider
or I can discontinue the telemedicine consult.

I also understand that I have the right to refuse or stop participation in telemedicine services at
any time and that it will not affect my right to future care or treatment.

I understand that all confidentiality protections required by law will apply to my care but
recognize that my healthcare information may be shared with other individuals and entities for
the purposes of providing continuity of care, billing and internal operations.

I understand that I have the right to inspect all information obtained and recorded in the course
of a telemedicine interaction and may receive copies of this information.

I understand that I may expect the anticipated benefits from the use of telemedicine in my care,
but that no results can be guaranteed or assured.

If an emergency occurs during a telemedicine encounter when I am at a non-health-care site, I
will call 911 and maintain the telemedicine encounter (if possible) until help arrives.

By signing this form, I certify:
That I have read or had this form read and/or explained to me.
That I fully understand its contents including the risks and benefits of a telemedicine encounter.
That I have been given ample opportunity to ask questions and that any questions have been
answered to my satisfaction and that I have been offered a copy of this Informed Consent Form.

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_____________________________________________ ____________
Signature of Patient or Parent or Legal Guardian Date

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_____________________________________________
Name of Parent or Legal Guardian (if applicable)

Rev January 1, 2025

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