Please review this before your appointment, the physician will confirm you have read and accept these terms as listed below.
Patient Authorization and Consent Form
Telemedicine lets a doctor or other healthcare provider care for you, even when you cannot see him or her in person. The doctor uses the Internet or other technology to:
Telemedicine can also be used to:
Telemedicine is more than a phone call, an email, a fax, or an online questionnaire. Sometimes you may need to come to a healthcare facility to use their equipment (TV screen, camera, or Internet). A provider may use need to use technology tools or medical devices to check on your health remotely. If you agree, part of your health record may be sent to the telemedicine provider before your session.
You and your healthcare team must decide if your health problem can be helped with telemedicine. The team and others involved in your care (e.g., medical home or hospital teams) will make a plan for your care using telemedicine. This will also include a plan in case you have an emergency during the telemedicine session.
If the patient is a minor child, the telemedicine provider will explain to the parent how a telemedicine exam is different from an in-person exam. He or she will also explain if a complete exam of the child is possible.
Your Telemedicine Session
During your telemedicine session:
All laws about the privacy of your health information and medical records apply to telemedicine. These laws also apply to the video, photo, and audio files that are made and stored.
Risks and Common Problems
Many patients like telemedicine because they do not have to spend time and money on travel to see a certain healthcare provider in person. Also, they can see a provider who they might not be able to see otherwise.
Technology can make getting health care easy, but there can also be problems:
A main goal of telemedicine is to make sure that you get good, personal health care, even though you are not seeing a provider in person.
Some states may require you to have a face to face visit first and a yearly visit with your doctor before telemedicine treatment can happen.
Telemedicine providers must follow the same rules for prescribing drugs just as they would for an office visit. Before your session, you will learn about which drugs telemedicine providers can and cannot prescribe.
Having a telemedicine session is your choice. Even if you have agreed to the session, you can stop your medical records from being sent – if this has not happened yet. You can stop the session at any time. You can limit the physical exam.
You will be told about all staff who will take part in the session. You can ask that any of these people leave the room to stop them from seeing or hearing the session. It is up to you to make sure the setting for your session is private. It should only include people who you are willing to share health information with. Your telemedicine provider can ask that people with you leave the room to make sure your session is private.
Your session may end before all problems are known or treated. It is up to you to get more care if your health problem does not go away.
You will be told how long it might take to respond to your emails, phone calls, or other types of messages.
Before your session, you may want to ask how much of the cost will be covered by your insurance and how much you may owe.
This form gives you facts about and risks of telemedicine sessions. By signing this form, you agree that you have read, understand, and agree with these terms.
I also confirm that: