123 Dwight Road Longmeadow, MA 01106
(413)567-1031 Fax(413)567-7683
115 Elm Street Enfield, CT 06082
(860)745-3336 Fax(860)741-2654


Telehealth technology will be used to connect me with a provider from our practice. I understand that this encounter will not be the same as a direct patient/health care provider visit. I will not be in the same room as my health care provider. I understand that during this encounter my health care provider cannot use devices such as a stethoscope or otoscope or other peripheral devices to assist in the examination. A full, comprehensive examination is not possible under these circumstances.

There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. My health care provider or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the telehealth appointment at any time

My healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the appointment other than my healthcare provider and specialty health care provider in order to operate the equipment. The above mentioned people will all maintain confidentiality of the information obtained. You will be informed of their presence during the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination room; and/or (3) terminate the telehealth appointment at any time.

Not all medical problems can be addressed through Telehealth. We may need to have you bring your child to see us in person for a proper evaluation.

Billing for the telehealth visit will be at the same rates as an in-person visit to our office. You will be responsible for any copays, co-insurance, or deductibles as per your insurance contract.

By participating in a Telehealth encounter, you  consent to participate in a telehealth appointment visit under these terms.