forms test

I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Pediatric Potentials providing health care services to me via telemedicine. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit. I understand that I will be responsible for any copayments or coinsurances that apply to my telemedicine visit. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Pediatric Potentials at 406-582-4182. As long as this consent is in force (has not been revoked) Pediatric Potentials may provide health care services to me via telemedicine without the need for me to sign another consent form.

Patient Information

Parent/Guardian Information

Please provide the best information for each parent/guardian as applicable.

(or the person authorized to sign for the patient): ________________________________________________________


If authorized signer, printed name and relationship to the patient: ________________________________________________________