Clinical Treatment Informed Consent

Last modified: July 2022

CLINICAL TREATMENT INFORMED CONSENT - Clarity Pediatrics Medical Group

Addendum to Telehealth Informed Consent

Luis Alesandro Larrazabal Martinez, M.D., P.C., (d/b/a Clarity Pediatrics Medical Group) working with its affiliates and its engaged clinicians (collectively, “Provider”) provides telehealth-based professional clinical treatment to its patients through individual physicians and health care professionals. When you seek services from Provider, you will be connected with a personalized care team.

Your care team is here to help you with your health and well-being, and other important areas of your life through psychotherapy, counseling, and other health care services. Provider care team members will ask you questions, listen to you and suggest a plan for improvement. Your Provider care team will discuss your course of treatment with you, the risks and benefits of such treatment, and privacy and confidentiality connected with your treatment.

Parent/Guardian (If patient is a minor and unable to consent):‍

By signing below I acknowledge and confirm that Provider has discussed with me, on behalf of my minor child (or individual of whom I am legal guardian) (collectively the “Patient”), the relevant information pertaining to the Patient’s course of treatment so I may be properly informed of such treatment, treatment risks and benefits, and privacy and confidentiality matters.  I understand the information discussed and further understand that this consent is in addition to the Informed Telehealth Consent, which was executed in connection with receiving services from Provider via telehealth. I understand that I may ask Provider, on behalf of the Patient, questions related to the Patient’s care at any time.  I also understand that there may be certain limitations as to information which I may request from Provider or what Provider may be allowed to tell me about the Patient’s treatment pursuant to applicable law and rules.