Thank you for choosing us for your telehealth care. Consent for telehealth services
is an important aspect of remote healthcare delivery to ensure both clients and
providers are on the same page regarding the treatment being provided. We want
you to understand your rights and responsibilities while receiving care from us.
If you have any questions about this form, please feel free to reach out at any time.
If you are a parent/legally-authorized representative of a child, please read this
agreement with the understanding that “I” and “me” means the child.
1. Consent for Treatment: I consent to telehealth care performed by the BCBA and
the Paraprofessional at Shine ABA Solutions. These services may include
assessment, intervention, consultation, and training related to behavior analysis
and skill development. I understand that these services will be provided through
video calls and other telecommunication technologies. I understand that I have
the option to refuse the delivery of health care services by telehealth at any
time without affecting my right to future care or treatment, and without risking
the loss or withdrawal of any benefits to which I would otherwise be entitled.
2. Consent for Telehealth Services:
Telehealth involves transmission of video. I understand that:
● I will be informed of any other people who are present at either end of the
telehealth encounter, and have the right to exclude anyone from either location.
● All confidentiality protections required by law or regulation will apply to my
care.
● I have the right to refuse or stop participation in telehealth services at any
time and request alternate services such as an in-person service. However, I
understand that equivalent in-person services might not be available at the
same location or time as telehealth services.
● If I do not want to receive services by telehealth, it will not affect my right
to future care or treatment, or any insurance/ program benefits to which I would
otherwise be entitled.
3. Records and Release of Information: Transmitted Data may become part of my
medical record. Data will not be transmitted to people outside my health care
team except as described below, and/or if I provide additional written consent.
● I will have access to all of the information in my medical record resulting
from the telehealth services that I would have for a similar in-person visit, as
provided by federal and state law.
905 -07 West Beech Street, Long Beach NY 11561
2307 Coney Island Avenue 2nd floor, Brooklyn, NY 11223
Tel: (516)-615-2211
●The Providers may use or disclose my health information for treatment, continuity
of care, payment, or internal operations, or when required by law or regulation in
certain unique situations.
●All releases of information are subject to the same laws and regulations as in-
person care.
4. Benefits and Risks:
I acknowledge that the benefits of ABA telehealth services include convenience,
reduced travel, and the ability to receive ABA services in the comfort of my own
home. I also understand that there may be risks and limitations associated with
telehealth, including potential technical issues, interruptions in communication, and
limitations in direct physical interaction for assessment.
5. Privacy and Security:
I understand that my personal and health information will be collected and stored in
compliance with applicable privacy laws. I acknowledge that appropriate security
measures will be in place to protect the confidentiality of our telehealth sessions.
6. Informed Consent:
I have been provided with an explanation of the proposed ABA treatment plan and
goals that will be addressed through telehealth. I have had the opportunity to ask
questions and seek clarifications regarding the ABA telehealth services.
