Telehealth Consent Form
Mothers Milk Matter
- I hereby authorize Mothers Milk Matter to use the telehealth practice platform for telecommunication to evaluate, test, and diagnose my medical condition.
- I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
- I accept that the professionals can conduct interactive sessions with video calls; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
- I understand that this is a private pay, & payments should be done upfront. We don’t deal with Insurance.Â
- any information that needs to be contacted will be sent Via HIPPA regulation via email to the provider or updates necessary for telehealth & personal visits.Â
- If the cancellation is not notified in 24 hours, $50 will be charged.
- I agree that my medical records on telehealth can be kept for further evaluation, analysis, and documentation, and my information will be kept private in all of these.
