Informed Consent and Agreement for Telehealth Services

 

Consent to Telehealth

 

I understand that checking the “I agree” box below, or providing my signature, handwritten or in electronic format of any kind, on this document constitutes my legal signature. In checking the appropriate box or providing my signature on this document, in any form, I am confirming that I understand and agree to its terms. 

 

Definition of Telehealth

 

1. For the purposes of this document, telehealth is defined as the electronic communications technologies used by the Provider and staff at Grateful DPC, PLLC (together, the Practice), to enable them to obtain information and communicate remotely while providing me with patient care. I understand that the same standard of care applies to medical treatment obtained through telehealth communications as applies to an in-person visit. The information obtained through telehealth communications may be used for diagnosis, treatment, follow-up and/or education and may include any of the following:

 

• Patient medical records

• Medical images
• Live two-way audio and video and data communications
• Output data from medical devices and sound and video files
• Questionnaires, email, and text messaging

 

The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

 

Understandings

 

I Understand that:

 

Telehealth involves the communication of my health information in an electronic or technology-assisted format;

 

All electronic medical communications carry some level of risk;

 

Despite reasonable security efforts, it is possible for electronic communication to be forwarded, intercepted, or changed without my knowledge;

 

Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided;

 

It is important for me to use a secure network; 

 

Despite reasonable efforts on the part of my Provider, the transmission of medical information could be disrupted or distorted by technical failures;

 

I may opt-out of the telehealth visit at any time;

 

The Practice will maintain information exchanged during my telehealth visit as part of my Medical record; 

 

Neither the Practice nor my Provider is responsible for breaches of confidentiality caused an independent third party or by myself;

 

I must verify my identity and current location to my Provider and failure to do so may terminate the telehealth visit;

 

Electronic communication cannot be used for emergencies or time-

sensitive matters;

 

I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.);

 

A medical evaluation via telehealth may limit my Provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my Provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit;

 

There is never a warranty or guarantee as to a particular result or

outcome related to a condition or diagnosis when medical care is provided;

 

By electronically signing or checking the box below, I am certifying that understand the inherent risks of errors or deficiencies in the

electronic transmission of health information and images during a telehealth visit;

 

Possible Benefits of Telehealth

 

• Easier access to medical care;
• Convenience;
• More time-efficient medical evaluation and management

 

Possible Risks of Telehealth

 

As with any technology used in medical care, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

 

• Information transmitted may not be sufficient to allow for appropriate medical decision making by the Provider;
• Provider may not be able to provide medical treatment for your particular conditions remotely;
• Regulatory and other requirements may limit your Provider’s ability to provide certain treatment options, including prescriptions;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment;
• Security protocols could fail, resulting in privacy breaches of personal medical information;

 

By checking the box below, I certify that I have read this document and understand it. I have had the opportunity to have any questions answered. I understand this document in its entirety, and I consent to participation in telehealth. I understand that I may have a hard copy of this Informed Consent upon request. 

 

• I Agree

 

Signature__________________________________________________________________

                                           (Printed Name)

Date: _________________

 

Relationship to Patient: __________________________________________________