Medical Provider's Telehealth Policy
Informed Consent
What Is Telehealth?
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Blueberry Pediatrics may include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services (e.g., patient education).
Information you provide may be used for diagnosis, therapy, follow-up, and/or patient education, and may include any combination of the following:
Health records and test results
Images and asynchronous communications
Live two-way audio and video
Interactive audio with store-and-forward
Output data from medical devices and sound/video files
The electronic communication systems we use incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, with measures to safeguard the data and ensure its integrity against intentional or unintentional corruption.
Note: Blueberry Medical PA providers (our “Providers”) are an addition to, not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one. We strongly encourage you to locate one if you do not.
Expected Benefits
Improved access to care by enabling you to remain in your home while the Provider consults and obtains test results at distant/other sites
More efficient care evaluation and management
Access to specialist expertise, as appropriate
Possible Risks
Delays in evaluation and treatment due to equipment or technology failures
In rare events, the transmitted information may be of inadequate quality, requiring a rescheduled telehealth consult or a visit with your local primary care doctor
In very rare events, security protocols could fail, causing a breach of privacy of personal medical information
In rare events, lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors
If You Need Follow-Up or Help
If you need follow-up care, assistance after an adverse reaction, or cannot communicate due to a technological failure, contact Blueberry Pediatrics at (754) 702-7256 or info@blueberrypediatrics.com.
Your Consent (Acknowledgments)
By checking the box associated with “Informed Consent,” you acknowledge that you understand and agree to the following:
Consent to Telehealth. I consent to receiving Blueberry Pediatrics’ services via telehealth technologies. I understand Blueberry Pediatrics and its Providers offer telehealth-based medical services, but these do not replace my relationship with my primary care doctor. The Provider will determine whether my clinical needs are appropriate for telehealth.
Choice of Provider. I was given an opportunity to select an available on-call Provider from Blueberry Pediatrics prior to the consult, including reviewing the Provider’s credentials.
Privacy & Security. I understand federal and state law requires protection of my health information. Blueberry Pediatrics will take steps so that identifiable information is not seen by unauthorized persons. Telehealth may involve electronic communication of my medical information to other practitioners, including those out of state.
Technology Limitations. I understand there may be technical failures beyond Blueberry Pediatrics’ control. I agree to hold Blueberry Pediatrics harmless for delays or information loss due to such failures.
Right to Withdraw. I may withhold or withdraw consent to telehealth at any time without affecting my right to future care. I may suspend or terminate use of telehealth services at any time. If I am experiencing a medical emergency, I will dial 9-1-1; Providers cannot connect me directly to local emergency services.
Alternatives. Alternatives to telehealth (e.g., in-person services) are available. Some tests may be conducted at my location or a testing facility at the Provider’s direction (e.g., labs, bloodwork).
No Guarantees. I may expect benefits from telehealth, but no results are guaranteed or assured.
Care Team & Observers. My information may be shared for scheduling and billing. Persons other than the Provider may be present to operate telehealth technologies. I will be informed of their presence and may (a) omit personally sensitive details, (b) ask non-medical personnel to leave, and/or (c) terminate the consultation at any time.
Controlled Substances. I will not be prescribed narcotic pain medications via telehealth, and there is no guarantee that any prescription will be provided.
Medical Records. If I participate in a consultation, I may request a copy of my medical records. Copies will be provided at reasonable cost of preparation, shipping, and delivery.
Home Devices. I may be directed to use devices (e.g., thermometer, pulse oximeter, at-home tests, or other peripherals) to assist in providing telehealth.
Questions Answered. I have discussed telehealth with my Provider, had the opportunity to ask questions, and received answers regarding risks, benefits, and alternatives in a language I understand.
Patient Consent
I have read this document carefully, understand the risks and benefits of telehealth, and had my questions answered. I hereby give my informed consent to participate in a telehealth consultation under the terms described.
By checking the box labeled “INFORMED CONSENT FOR TELEHEALTH SERVICES,” I certify:
I have read or had this form read and/or explained to me.
I fully understand its contents, including risks and benefits of the procedure(s).
I have had ample opportunity to ask questions, and all questions have been answered to my satisfaction.