1. PURPOSE: The purpose of this form is to obtain your consent to participate in a
telemedicine consultation in connection with the following procedure(s) and/or service(s): Occupational,Physical, Speech, and/or Feeding Therapy
2. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:
a. Details of your medical history, examinations, x-rays, and test will be
discussed with other health professionals through the use of interactive video, audio, and telecommunication technology. b. A physical examination of you may take place. c. A non-medical technician may be present in the telemedicine studio to aid in the video transmission. d. Video, audio and/or photo recordings may be taken of you during the procedure(s) or service(s)
 4. CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telemedicine consultation.
 5. RIGHTS: You may withhold or withdraw consent to the telemedicine consultation
at any time without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
 6. DISPUTES: You agree that any dispute arriving from the telemedicine consult will be resolved in
Georgia, and that Georgia law shall apply to all disputes.
 7. RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences and benefits of telemedicine. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered, and you understand the written information provided above.