The main venue for my (insert drop down for: psychotherapy, occupational therapy, physical therapy, speech therapy, medical nutrition therapy, ABA therapy) treatment will be Pediatric Advanced Therapy offices at one of the addresses listed on their website. I understand that telehealth includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications. I understand that telehealth also involves the communication of my medical/mental health information, both orally and visually, to other health care practitioners. I understand that I have the following rights with respect to telehealth:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. (See HIPAA Notice of Privacy Practices forms, provided to me, for more details of confidentiality and other issues.) I also understand that the dissemination of any personally identifiable images or information from the teletherapy interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from telehealth. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner. In addition, I understand that telehealth based services and care may not yield the same results nor be as complete as face-to-face service. I also understand that if my therapist believes I would be better served by another form of psychotherapeutic service (e.g. face-to-face service), I will be referred to a therapist in my area who can provide such service. Finally, I understand that there are potential risks and benefits associated with any form of therapy, and that despite my efforts and the efforts of my therapist, my condition may not improve.

(4) I understand that I may benefit from teletherapy, but results cannot be guaranteed or assured. The benefits of telehealth may include, but are not limited to: finding a greater ability to express thoughts and emotions; transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for therapy sessions.

(5) I understand that I have the right to access my medical information and copies of medical records in accordance with North Carolina law. I have read and understand the information provided above, which has also been explained to me verbally. I have discussed it with my therapist, and all of my questions have been answered to my satisfaction.

(6) I understand that insurance companies may revoke the coverage/reimbursement for telehealth services at any point and Pediatric Advanced Therapy is not responsible for these changes.

(7) I understand that it is required that the client is in the state of NC in order for treatment sessions to be conducted due to state licensing requirements. I understand that if I am out of state, my session will be cancelled, and I can schedule a make up session the following week when I am back in town as available.