Telemed Consent

TELEMED CONSENT

CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION (for DR Care 24/7

I seek the telemedicine consultation of {productname}. I am executing this Consent to Participate in Telemedicine Consultation (“Telemedicine Consent”) to verify and confirm my discussion with {productname} regarding the risks, benefits, and alternatives to telehealth consultation services through Practice. I understand that all diagnoses and treatments are provided by an independently contracted licensed medical professional (“Provider”). I am seeking the telemedicine consultation services of Practice for my own purposes and not on behalf of any third party. I understand that I am a participant in the decision-making process, and I am free to decline services or treatments at any time. I retain the option to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. I acknowledge that Provider may, in his or her sole discretion, determine whether the nature of my consultation is inappropriate for telemedicine, and may require me to come in for an in-person consultation.

1. Purpose. The purpose of this form is to obtain your consent for the use of telemedicine consultations with Provider. The purpose of the use of telemedicine consultations is to assist in the care and services provided by Practice and ultimately to assist in

2. Nature of Telemedicine Consultation. 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 educational purposes. During your telemedicine consultation, details of your medical history and personal history information may be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken.

3. 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 health care community. Additional benefits are that patients may be diagnosed and treated earlier which can contribute to improved outcomes and less costly treatments. Potential risks of telemedicine include 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. Practice has taken the following steps to ensure the privacy of the telemedicine consultation: We use only HIPAA compliant software through our Electronic Medical Record (EMR) software, teleconferencing software, and other electronic service providers.

In rare instances, technology failure may lead to the loss of information provided through telemedicine consultations. Additionally, in rare instances, security protocols could fail, causing a breach of patient privacy. In rare cases, a lack of access to complete and/or accurate medical records or information may result in adverse drug reactions, allergic reactions, or other judgment errors. You agree to hold Provider and Practice harmless from any such information loss, and any resulting judgments or decisions, due to technical failures outside of their agency or control. The quality of transmitted data may also affect the quality of the services provided via the telemedicine consultation. The alternative to telemedicine consultation is a face-to-face visit with a physician.

4. Medical Information and Records. All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation shall not occur without your consent.

5. Confidentiality. All existing confidentiality protections under federal and state law apply to information used or disclosed during your telemedicine consultation. However, there are both mandatory and permissive exceptions to confidentiality, which may allow or require disclosure of information used or disclosed during the telemedicine consultation. You will be informed of any parties who will be present from the Practice during your telehealth consultation, and will have the opportunity to exclude anyone from attending the consultation.

6. Rights. You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consultation without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the right to be informed of and object to videotaping or other recording of the consultation.

By agreeing, I acknowledge that, I have read and fully understand the foregoing Telemedicine Consent, and I have all of the knowledge I currently desire.