LEAD716 Consent to Telehealth Services and Treatment


Because of the COVID-19 Emergency, your family will receive LEAD716 services at a safe distance by electronic communications. 


This form is to help you understand and agree to telehealth for your child. Telehealth means your LEAD716 providers will communicate electronically from different locations to share medical information to help us provide good care. To help LEAD716 diagnose, provide therapy, follow-up and/or education, we may use technology to connect: Medical records, live two-way audio and video, output data from medical devices and sound and video files.




LEAD716 is focused on protecting your personal information. The technology LEAD716 providers use to communicate with you have network and software security protocols to protect personal information. LEAD716 will enable all security protocols available including encryption.


Expected Benefits:


Improved access to care, useful evaluation and case management, obtaining services from a distance.


Possible Risks:


Delays in evaluation and treatment can occur because of technological interruptions or failures. 

In rare circumstances, security protocols could fail and your personal information may be breached. 


By signing this form, I understand the following:


  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies my child, will be disclosed to researchers or other entities without my consent.

  2. I understand that I can choose not to consent or withdraw consent to telehealth services any time. 

  3. I understand that if I do not consent or withdraw my consent to telehealth LEAD716 cannot provide in person services during COVID-19 Emergency. 

  4. I understand that I have the right to review all information obtained and recorded in telehealth sessions. I understand I can access copies of this information if I send a written request to LEAD716 c/o LDA of WNY 2555 Elmwood Avenue, Kenmore, NY 14217, 716) 874-7200.

  5. I understand that I may expect the anticipated benefits from the use of telehealth in my child’s care, but that no results can be guaranteed.


Parent/Guardian Consent to the Use of Telehealth


I have read and understand the information provided above regarding telehealth and all of my questions have been answered to my satisfaction. I hereby give my informed consent to the use of telehealth in my child’s care.

©2020 Learning Disabilities Association of WNY