Please review this before your appointment, the physician will confirm you have read and accept these terms as listed below.

Telemedicine Session

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:

  • give you advice,
  • give you an exam, or
  • do a procedure through online communications.

Telemedicine can also be used to:

  • get prescription refills,
  • book an appointment, or
  • let your doctor talk with other providers about your health problem or treatment.

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:

  • The provider and the staff will introduce themselves.
  • When starting a session, you may be asked to confirm the state you are in and the state where you live.
  • The provider may talk to you about your health history, exams, x-rays, and other tests. Other providers may take part in this discussion.
  • A visual and/or partial physical exam may take place. This may happen by video, audio, and/or or with other technology tools. A nurse or other healthcare staff may be in the room with you to help with the exam.
  • Non-medical staff may be in the room to help with the technology.
  • Video and/or photo records may be taken, and audio recordings may be made.
  • A report of the session will be placed in your medical record. You can get a copy from your provider.

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:

  • If there is an equipment or Internet problem, your diagnosis or treatment could be delayed.
  • Records or images that are taken and sent may be poor quality. This can delay or cause problems with your diagnosis or treatment.
  • The records sent for review before the session may not be complete. If this happens, then it may be hard for the telemedicine provider to use his or her best judgment about your health problem. For instance, you could react to a drug or have an allergic response if the provider does not have all of the facts about your health.
  • There could be problems with Internet security and privacy. For instance, hackers may access or view your health information. If this happens, then your medical records may not stay private.
  • If there is a technology problem, the information from your session may be lost. This would be outside the control of your doctor and the telemedicine provider.
  • Without a hands-on exam, it may be hard to diagnosis your problem.

More Facts

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.

Patient Acknowledgment

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:

  • I have been told the name and credentials of my telemedicine provider,
  • I have been able to ask questions about telemedicine sessions,
  • all of my questions have been answered,
  • I understand no guarantees have been made about success or outcome, and
  • I agree to take part in a telemedicine session.




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