Informed consent

General acceptance by patients.
Telehealth Services (also known as telemedicine, for example, interactive video, remote video surveillance, store and forward, or other interactions with electronic media) give you the ability to communicate with your health care team or your health care team. to communicate with each other without having to be in the same physical location. You can communicate with your health team using technology, such as a mobile device, tablet or computer

Telehealth services are not an option for all of your care needs. Your provider may need to see you in person to ensure medical conditions.

No video, audio or photo recording will be taken of you in the course of telehealth services without your consent.

AS A PATIENT I ACCEPT AND UNDERSTAND THE FOLLOWING:

I understand that I may see my healthcare team using this technology for some of my care needs.
I understand that a portion of my care may be provided by a telehealth provider who is not present in the room with me.
I understand that my telehealth provider may not perform an in-person physical examination of me at the time my telehealth services are provided.
I understand that the technology platforms used for telehealth sometimes malfunction. I or my healthcare team may stop or cancel a telehealth service if the technology is not working properly or if my healthcare team determines that the provision of telehealth services will not adequately address my medical needs.
In general, I have the right to cancel my telehealth service without affecting my ability to receive care in the future.
There may be exceptions to my right to cancel the visit/consultation for clinical and safety reasons.
A healthcare provider will explain to me how telehealth services will be delivered.
I understand that the laws that protect the privacy and confidentiality of medical information also apply to telehealth services and that no information obtained in the use of telehealth services that identifies me may be disclosed to researchers or other entities or used as part of a research study without my consent, except as otherwise permitted by law.
I understand that alternative forms of communication are available between a physician and myself for urgent care matters.
I may receive more than one bill related to my telemedicine services. I understand that my telemedicine provider may be an independent consultant and that this consultation may result in separate charges from the telehealth provider. I also understand that my telemedicine service provider cannot be an employee of the health care provider/hospital from which I am receiving treatment. I further understand that I am responsible for the self-pay (co-pay, deductible, etc.) portion of all billing related to these interactions. I understand that if telehealth services are not a covered service by my insurance carrier, I may be responsible for the entire bill.
PATIENT ACKNOWLEDGMENT FOR THE USE OF TELEHEALTH/TELEMEDICINE SERVICES –

Patients accept that they have read and understood the articles defined in the Telemedicine Services Acknowledgment Form mentioned above.