I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to the above provider providing healthcare services to me via telemedicine.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I understand there are potential risks to the technology, including interruptions and technical difficulties. I understand that my healthcare provider and I can discontinue the telemedicine visit if is felt that the video conferencing connections are not adequate for the situation. As always, my insurance carrier will have access to my medical records for quality review and audit.
I understand that I will be responsible for any copayments or coinsurances that apply to the telemedicine visit.
I understand that a medical evaluation via telemedicine may limit my healthcare provider's ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider's recommendation — including further diagnostic testing or an in-office visit.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting the above provider. As long as this consent has not been revoked, the above provider may provide healthcare services to me via telemedicine without the need for me to sign additional consent forms.