Telemedicine Consent Form

JMA continues to be committed to providing exceptional care to our patients.  We are excited to offer Telemedicine appointments for your children.

Telemedicine is the delivery of health care services when the provider and patient are not in the same physical location. Information is transmitted electronically, in our case, through interactive audio and video.  We are using a Telehealth platform called “Doxy.me” which is free for you and allows you to be securely connected with your provider through any smartphone or a computer with a webcam.

Potential Benefits Include:

• Improved access to medical care by enabling a patient to be at home for consultation and evaluation, rather than in one of JMA’s office locations.
• More efficient medical evaluation and management

Potential Risks Include:

• Occasionally, information transmitted may not be sufficient (poor quality image or audio) to allow for appropriate medical decision making by your provider.
• Delays in medical evaluation and treatment could occur due to deficiencies or failure of equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy or personal medical information.
• Not all medical conditions can be addressed through telemedicine and a follow up appointment may need to be scheduled.

When you request a tele-visit, you will either be scheduled an appointment or added to the que for urgent appointments. When the provider is ready for your visit, you will be invited via a text message from your phone.  By clicking on the link to start the visit, you are consenting to the following; 

• I consent to treatment via the Telemedicine platform.
• I understand that Telemedicine has limits and cannot always replace an in-office visit. I agree that I am willing to accept all risks associated with these limits.
• I understand that the telemedicine visit is a billable medical encounter.
• I agree to pay all copayments or coinsurance that may apply to the visit as per my insurance carrier.
• If my insurance denies the visit, I agree that I am responsible for payment.
• I authorize Jeffers, Mann and Artman Pediatrics to release medical information to my insurance company and accept the assignment of benefits.
• In the event that the Telemedicine provider believes my child needs to be seen in the office, I understand that an insurance claim will then be billed to my insurance company and I will be responsible for any copays or coinsurance.  

Thank you for trusting JMA Pediatrics as your child’s medical home.  We hope that this new Telemedicine service will bring a little extra comfort in these difficult times.