Telemedicine Consent Form

PURPOSE: The purpose of this form is to obtain your consent for a telemedicine consultation with our physician.

NATURE OF TELEMEDICINE CONSULT: Telemedicine involves the use of audio, video, or other electronic communications to interact with you, consult with your healthcare provider, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, and/or education.  During the telemedicine consultation,

1. Details of your medical history, examinations, x-rays, and tests will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.
2. A physical examination of you may take place
3. A non-medical technician may be present in the telemedicine studio to aid in the video transmission
4. Video, audio, and/or photo recordings may be taken of you during the procedure or service. 

RISKS, BENEFITS, AND ALTERNATIVES: The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local healthcare community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician. 

PATIENT RIGHTS: 

1. The laws that protect privacy and the confidentiality of medical information including (HIPPA) also apply to telemedicine. Please note that not all telecommunications are recorded and stored. Dissemination of any patient-identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.
2.  I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. 
3.  I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.

By signing this form, I understand the following:

1. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
2. I understand that my medical records on telehealth can be kept for further evaluation, analysis, and documentation, and in all of these, my information will be kept private.
3. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state. 
4. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
5. I understand that Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.

•  I hereby authorize Health Care Services to use the telehealth practice platform for telecommunication for evaluating, testing, and diagnosing my medical condition.

• I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. I understand that this informed consent will become a part of my medical record.