Telehealth Consent

To better serve the needs of patients, our services may be available by telehealth (two-way interactive video communication and electronic transmission).  This consent explains telehealth care.  If you have any questions, please ask your provider.

I understand that I may be evaluated and treated via telehealth and agree to the following:

1. Telehealth Services: Telehealth involves transmission of video or digital photographs of me, and/or details of my health (“Transmitted Data”). All Transmitted Data is sent via electronic means to my provider(s) to facilitate health care services. I understand that:

  • Telehealth is different from traditional care in that the patient and provider do not meet physically in-person.
  • Patients will be informed of any additional personnel that are to be present, seen or unseen, during the encounter. Patients must inform their Provider of any person other than the patient who is present. Patients have the right to exclude anyone from either location.
  • Patients have the right to refuse or stop participation in telehealth services at any time and request an in-person appointment, however, equivalent in-person services might not be available at the same location or time as telehealth services. A refusal to participate in telehealth will not affect rights to future care or benefits to which a patient may otherwise be entitled.
  • Patients have the right to follow-up with their provider as necessary with questions or concerns.
  • Benefits of telehealth include that the patients and providers can continue health care services when an in-person appointment is not possible or is inconvenient. The provider can also visualize some of the client’s environment. Telehealth may also minimize exposure to illness.
  • There are also risks involved in telehealth including, without limit, losing the ability to:
    • perform aspects of a physical examination (for example listening to the patient’s heart and lungs or verifying vital signs);
    • read physical or vocal cues/tones, and facial expressions;
    • provide immediate emergency physical services/care.

    Additionally, technical issues may disrupt the visit. There are also risks to preserving confidentiality including the risk that communications may be overheard; and that communications may be accessed by unknown third-parties.

  • Patients shall have to access to all medical information resulting from the telehealth services as provided by applicable law for patient access to medical records.

2. Confidentiality:

  • All confidentiality protections required by law or regulation will apply to my care.
  • Although confidentiality extends to communications by text, email, telephone, videoconference and other electronic means, providers cannot guarantee that those communications will be kept confidential and/or that a third-party may not gain access to such communications. With electronic communication, there is always a risk that communications may be compromised, unsecured, and/or accessed by a third-party.
  • To help maintain confidentiality when engaging in electronic health services, it is important that all sessions be conducted in a confidential place. This means that clients agree to participate in telehealth only while in a room or area where other people are not present and cannot overhear the conversation. Do not have sessions in public places.
  • Sessions may not be recorded and patients must seek written permission before recording any portion of the session and/or posting any portion of sessions.

3. Emergencies:

  • Telehealth is not appropriate if a patient is experiencing an emergent health care situation.
  • If an emergency occurs or a client is in a state of crisis, call 911.
  • If an emergency occurs during a telehealth encounter, call 911 and stay on the video connection (if possible) until help arrives.
 

I have read and agree to the terms in the Telehealth Consent. I understand that telehealth is not a substitute for in person health care services. I understand that telehealth is not appropriate if I am experiencing a crisis or having suicidal or homicidal thoughts. In case of emergency situations, I will contact 911.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.

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