Telehealth Consent Form for Franconia Pediatrics
This is an addendum to original patient paperwork in office.

I also understand that:

•I can decline 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 practitioner in-person if I decline the Telehealth Service.

•If I decline the Telehealth service, the other options/alternatives available for me, including in-person services are available in our office.

•The same confidentially 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 anyone else without my additional written consent.

•I will be informed of all people who will be present at all sites during my Telehealth service.

•I agree to an “in-person” visit if the doctor decides is necessary.

•While many states have ‘pay parity’ for Telehealth (visits covered as if delivered in the office), VA currently does not require insurers to cover such care. If your insurance does not pay, virtual visits will be charged a fee of $60.

•If you have State Issued Health Insurance (Virginia Medicaid), you will not be responsible for payment.

•Therefore, by signing this consent, I am giving permission to release information to my insurance company or third party payer.

I have read this document carefully, and my questions have been answered to my satisfaction. I understand that this consent is valid for 1 year from date signed.
Email *
Patient's Name *
date of birth (PATIENT) *
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Patient (if 18 & up) or Parent/guardian signature (type your name in as a signature) *
Today's Date *
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A copy of your responses will be emailed to the address you provided.
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