Telehealth Waiver Form Telehealth Waiver In an effort to continue to provide our clients with the support Connect Plus Therapy now offers a Telehealth option. Should you wish to utilize this option you must read the below requirements and sign the agreement. Parent/ Guardian Name First Last As the Parent/ Guardian, I would like to utilizetelehealth services through Connect Plus Therapy to continue to receive ABA services for my child. If he/she can no longer be safely managed through distance technology, I am aware that I can request for this service to either be modified or discontinued.Client (Child Name) First Last Client Date of Birth* MM slash DD slash YYYY Consent* I agree to the privacy policy.I understand that I am required to utilize the video conferencing application that Connect Plus Therapy has provided for me while receiving telehealth services. This is to ensure that the necessary confidentiality, and security parameters are met under Federal, State, Local, and HIPAA compliance. I also understand that I am responsible for ensuring that we have the technical capabilities to receive this service including the proper equipment and a clinical environment. I am able to set up the video conferencing system, maintain the appropriate computer/device settings, establish a private space, and cooperate for effective safety management. Both locations utilized during telehealth sessions are considered a patient examination room, regardless of the rooms intended use. Privacy must be ensured that clinical discussions cannot be overheard outside of either room. All parties involved with telehealth services are expected to maintain the same level of professional and ethical discipline and clinical practice standards as in person services. Parent or Guardian Signature*Date MM slash DD slash YYYY
