CONSENT TO PARTICIPATE IN A BOSTON CHILDREN'S HOSPITAL

ASYNCHRONOUS TELEHEALTH ENCOUNTER

The StrabisPIX app (the "App") is a HIPPA-compliant, secure telehealth tool intended to simplify the process of submitting still images captured by your smartphone to your physician at Boston Children's Hospital. The asynchronous, delayed nature of submitting information via the App means that your Provider may not review your submission immediately. THIS APP SHOULD NOT BE USED FOR URGENT MEDICAL ISSUES OR COMMUNICATION WITH YOUR PROVIDER.

Please direct any questions to your Provider or contact us at: StrabisPIX@childrens.harvard.edu.

By using the App you acknowledge the risks and benefits of using the App and accept and consent to participate in a telehealth encounter via the App.

1. I hereby authorize my Boston Children's Hospital care provider and/or physician (the "Provider") to use telehealth services to assist him/her in making decisions about my care or the care of my minor child.
2. If this telehealth service is for my minor child, then I must provide consent prior to their use of the App.
3. Use of the App and submission of images should only be done at the request of your Provider.
4. I understand that telehealth involves the electronic exchange of my medical information from one site to another. Video conferencing, electronic transmission of x-rays or other still images, and remote monitoring of vital signs are examples of telehealth. I understand that I will be using telehealth services to transmit my health information, orally, digitally and/or visually, to my Provider at Boston Children's Hospital.
5. The benefit of telehealth is to allow my Physician to use interactive communication technology to communicate with me and to enhance my care.
6. The App is one of many methods my Provider may use to manage my care and I will not rely on the App for obtaining a medical opinion or diagnosis.
7. The potential risks of telehealth are that the privacy and security of transmitting health information cannot be guaranteed and that electronic exchanges may experience errors, delays, disruptions or distortions. However, I understand that Boston Children's Hospital has taken precautions to minimize these occurrences, and will protect the security of the information and keep it confidential in accordance with law and the App's Privacy Policy.
8. A telehealth encounter is very different from an in-person examination and my Physician will be limited to the information or images I provide him/her either in advance or during a telehealth encounter.
9. I understand that video, audio or photo recordings of my telehealth services may be made, stored or archived and may later be used for educational quality review. They may also become part of my medical record. I understand any such educational quality review use will be made in accordance with applicable patient confidentiality requirements and that retention of the recordings or still images will be subject to applicable deletion and destruction policies.
10. My, or my child’s, use of the App for a telehealth encounter is entirely optional. If I have concerns about using the App I will contact my provider prior to using the App.
11. In addition, I understand that my Physician may bill for his/her professional services and for any additional fees in connection with the services described above.
12. Finally, I understand that, regardless of any telehealth consultation services I may receive, my condition may require a referral to the clinic or specialist for further evaluation and treatment.
13. I have read this document carefully, and understand the risks and benefits of the telehealth encounter.

If you still have questions about the telehealth consultation, you should contact your Provider prior to using the App.