Telehealth Informed Consent

Throughout this Telemedicine Informed Consent, references to "you" and "your" refer to the patient and, where the patient is a minor or a legally incapacitated or otherwise consent-incapable individual, to the parent, legal guardian, or other person legally authorized to make healthcare decisions and provide consent on the patient's behalf (as further described in the section titled "Authority to Consent on Behalf of a Minor or Legally Incapacitated Individual")

What is Telemedicine?

Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner.

Benefits of Using Telemedicine

The benefits of telemedicine include having access to medical care anywhere you have access to the internet—including from the comfort of your home. Telemedicine means you don’t risk exposure to illness in busy waiting rooms, and you do not have to wait several days for an in-person appointment. Telemedicine also means you do not have to travel great distances to gain access to specialty care that may not be available in your community.

Possible Risks of Using Telemedicine

As with any medical treatment, there are potential risks associated with the use of telemedicine. These risks may include, without limitation, the following:

• Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor video and data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur. If you need assistance in the event of a telemedicine equipment failure, please contact us at: hello@foyerpediatrics.com.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• Because SL Medical PC d/b/a Foyer Pediatrics does not have access to your complete medical records, if you do not disclose to your Provider a full list of your medical history, including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions, or allergic reactions, or other negative outcomes may occur.
• Telemedicine services are NOT emergency services, and your personal data WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE PROVIDER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR A TELEMEDICINE ENCOUNTER VIA THE SERVICE.

Your Rights and Acknowledgements

• You understand that you have the option to refuse a telehealth visit at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any benefits to which you would otherwise be entitled.
• You understand that there are no additional or hidden fees associated with the use of telemedicine.
• You understand that your healthcare information may be shared with other individuals in accordance with the Foyer Pediatrics Privacy Policy and regulations or laws in the state or territory in which you are located. You further understand that you have the right to request disclosure of your Healthcare Information to any third party, and that such disclosure will be made upon Foyer Pediatrics’ receipt of your signed written authorization.
• You understand that dissemination of any identifiable images or information from the telemedicine visit to researchers or other entities will not occur without your express written consent.
• Telemedicine may involve electronic communication of your personal medical information to remote healthcare practitioners who may be located outside of your state.
• You have the same privacy rights via telemedicine that you would have during an in-person visit.
• You understand that no results can be guaranteed or assured—you may not achieve the anticipated benefits of the telemedicine services.
• You understand that a variety of alternative methods of medical care may be available to you, and that you may choose one or more of these at any time.
• You understand that all information submitted to Foyer Pediatrics will be part of your medical record, and you have the right to review and receive copies of your medical records in accordance with applicable law. For more information on how to access your medical records, please contact hello@foyerpediatrics.com.
• You understand that your telemedicine visit may be with a non-physician provider. You may request that your telemedicine visit be scheduled with a physician.
• You will provide your accurate physical location when asked by a Provider to ensure that Provider is licensed to provide telemedicine services to you. Your Provider will validate this prior to commencing your visit.
• You consent to the disclosure of any medical records prepared by Foyer Pediatrics to your primary care provider.

Use of AI Scribe Technology and Recording of Visits

You understand and consent to the use of artificial intelligence (AI) technology, sometimes referred to as an “AI scribe,” to assist your Provider during your telemedicine visit. We currently use Healthie as an AI Scribe and use Zoom Healthcare to record visits. These vendors may change. You understand that the AI scribe may listen to, record, transcribe, and summarize your visit in order to generate clinical notes and documentation for your medical record. You understand that your Provider will review any AI-generated documentation and remains responsible for the content of your medical record and for all clinical decisions. You understand that any information processed by the AI scribe may be disclosed to our third-party AI scribe vendor and will be handled in accordance with the Foyer Pediatrics Privacy Policy and applicable law, and that you may decline the use of the AI scribe at any time without affecting your right to care or treatment. You agree to the recording of the visit and also understand that the recording of the visit will be retained as part of your record.

This Telemedicine Informed Consent is valid for one (1) year from the initiation of your initial Telemedicine visit. If you would like to withdraw consent, you must do so prior to receiving any further treatment by emailing us at hello@foyerpediatrics.com. You agree that Foyer Pediatrics can rely on your consent, and that withdrawal of consent is not effective with respect to actions taken in reliance on your consent prior to the revocation. Your withdrawal of consent will not affect your right to future care or treatment.

Electronic Consent and Acknowledgment

By checking the box and submitting this Telemedicine Informed Consent, you acknowledge and agree that you have read, understand, and voluntarily agree to all of its terms, acknowledgements, benefits, and risks. You agree that checking the box constitutes your electronic signature and has the same force and legal effect as a handwritten signature, and that this Telemedicine Informed Consent is a binding agreement. You represent that you are at least eighteen (18) years of age (or, if consenting on behalf of a Patient, that you are the parent, legal guardian, or other person legally authorized to provide consent) and that you have the capacity and authority to provide this consent. If you are consenting on behalf of a Patient, you further represent that you have the legal right and authority to consent to telemedicine treatment for the Patient and to authorize the disclosure of the Patient’s healthcare information as described in this Telemedicine Informed Consent, and you consent to the Patient receiving telemedicine services from Foyer Pediatrics. You further consent to conduct this transaction electronically and to receive this Telemedicine Informed Consent and related records in electronic form.