I have read and understood this Telehealth policy and Consent document and I consent to receiving Itsverdure services via the telehealth  technologies described herein or as may otherwise become available and used by Itsverdure in the future. I understand that Itsverdure and its providers are a telehealth only medical service provider whose interactions with me are all electronic and that their services to me do not replace the relationship between mine or my children’s with their primary care provider. In that regard I understand that at all times I should consider Itsverdure to be a supplemental service to my child's primary care provider who remains responsible for managing my child's overall professional medical care. I also understand it is up to Itsverdure provider’s to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.                                                                                                                                                                                                                                                                                         

I have been given an opportunity to select from a list of Itsverdure on call providers prior to the consult, including a review of the Providers' credentials and that the choice of provider is solely mine to make
 

I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations or as otherwise required by applicable law. Further, I understand that “Itsverdure” will take reasonable actions to ensure that my identifiable protected health information ("PHI" as defined  by HIPAA) will not be accessible by any person except as provided herein. I understand that telehealth may involve electronic communication of my PHI to other health practitioners who may be located in other areas within the United States , and not just the state in which I or my child is located during the telehealth encounter with Itsverdure.
 

I understand there is a risk of technical failures during the telehealth encounter beyond the reasonable control of Itsverdure. I agree to hold harmless “Itsverdure” and its providers for delays in evaluation or for information lost due to such technical failures.
 

I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my child's care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
 

I understand that if I am experiencing a medical emergency, Itsverdure providers may not be able to assist virtually and that I will be directed to dial 9-1-1 immediately. I also understand that Itsverdure Providers are not able to connect me directly to any local emergency services.
 

I understand that alternatives to telehealth consultation, such as in-person consultation with a pediatrician are available to me, and in choosing to participate in a telehealth consultation with Itsverdure, I understand that some parts of the services involving tests may be conducted by individuals in  my local area when possible, or at a testing facility close to me,  at the direction of the Itsverdure Provider (e.g. labs or bloodwork).
 

I understand that I may expect the anticipated benefits from the use of telehealth in delivering my child's professional medical care, but that no results can be or are guaranteed or assured.
 

I understand that my child's healthcare information may be shared with other individuals for scheduling, billing and other purposes. Also, persons may be present during the consultation other than the provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request any or all of the following:   i) omit specific details of my child's medical history/examination that are personally sensitive to me;  ii) ask non-medical personnel to leave the telehealth examination;  and/or iii) terminate the consultation at any time.
 

I understand that Itsverdure Providers are prohibited from prescribing  any narcotics or other controlled substances for pain, nor is there any guarantee that my child will be given a prescription at all.
 

I understand that if I participate in a telehealth consultation, I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery in accordance to applicable laws.
 

I understand that I may be directed to use devices such as a thermometer, pulse oximeter, at-home tests, or other peripheral devices to assist in the provision of telehealth by Itsverdure's providers.
 

I will have a conversation with an Itsverdure provider, during which I will have the opportunity to ask questions in regard to the consultation and virtual encounter. I will have my questions along with the risks or benefits of any practical alternatives answered in a language that I understand and if not so, I will contact Itsverdure in writing within 24 hours of the consultation through the patient portal
 

I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by Itsverdure providers during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such providers may not have access to my full medical record or other relevant information held.
 

I agree that all my questions about this virtual encounter have been answered to my complete satisfaction prior to my telehealth appointment