Speech Therapy Telehealth Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________

Consent for Telehealth Services

I, _________________________, hereby consent to participate in telehealth services with [Practice Name] for speech-language therapy services.

Nature of Telehealth Services

1. Telehealth involves the delivery of speech therapy services using interactive audio and video technology, where the patient and speech-language pathologist are not in the same physical location.

2. The interactive electronic systems used will incorporate network and software security protocols to protect patient information and safeguard data.

Understanding and Agreements

I understand that:

• The same standard of care applies to telehealth as in-person sessions
• Laws protecting healthcare information and confidentiality apply to telehealth
• I have the right to withhold or withdraw my consent at any time
• Technical difficulties may necessitate rescheduling the session

Technology Requirements

I confirm that I have:

• A reliable internet connection
• A device with a camera and microphone
• A private, quiet space for sessions

Emergency Protocols

In case of emergency during a telehealth session:

• Emergency Contact Name: _________________
• Emergency Contact Phone: ________________
• Local Emergency Services Number: _________

Signatures

Patient/Guardian Signature: _________________ Date: _______

Provider Signature: ________________________ Date: _______

Privacy Notice

This telehealth service complies with HIPAA requirements and all applicable federal and state laws regarding patient privacy.