Telehealth Explanation and Informed Consent:

Telehealth involves the use of electronic communications to enable healthcare providers at different locations the ability to diagnosis, treat, transfer medical data, provide therapy, consults, follow-ups and/or education. Communication may be handled through:

  • Electronic transmission of information
  • Live chat
  • Phone / SMS
  • Or Video

The interactive 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.

Benefits may include:

Improved access to healthcare providers by enabling a patient to remain in his/her local site (i.e. home) while the provider consults and obtains test results at distant/other sites.More efficient evaluation and management.

  • Obtaining the expertise of a distant specialist.

Possible Risks:

Although uncommon, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

  • In rare cases, the consultant may determine that the transmitted information is of inadequate quality to allow for appropriate therapeutic decision making by the healthcare provider.
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing unauthorized persons access the electronic storage of my medical information.

By checking the box you are electronically signing this “Informed Consent”, You acknowledge that you understand and agree with the following:

  1. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telebehavioral health or telemedicine and that no information obtained in the use of service, which identifies me, will not be disclosed to researchers or other entities without my written consent.
  2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
  3. I understand that a variety of alternative methods of healthcare may be available to me and that I may choose one or more of these at any time. I understand that I may ask my treatment provider about alternative methods of care.
  4. I understand that telemedicine may involve electronic communication of my personal medical information to other clinical practitioners who may be located in other areas, including out of state.
  5. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  6. I understand that telehealth based services and care may not be as complete as face-to-face services. I also understand that if my telehealth provider believes I would be better served by another form of service (e.g. face-to-face services), I will be referred to locate a provider in my local area.
  7. I understand that there are potential risks and benefits associated with any form of treatment and that despite my efforts and the efforts of my telehealth provider, my condition may not improve, and in some cases may even get worse.
  8. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment.The above-mentioned people will all maintain the confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
  9. I understand that the information disclosed by me during any assessment or treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to information demonstrating a probability of imminent physical injury to myself or others; immediate mental or emotional injury to myself; and where I make my mental or emotional state an issue in a legal proceeding.

In cases of emergency, do not use Telehealth. Instead, call 911 immediately!

Patient Consent To The Use of Telehealth

I have read this document carefully, and understand the risks and benefits of telehealth and have had my questions answered and I hereby give my informed consent to participate in a telehealth consult under the terms described herein. I understand I have the opportunity to discuss it with my resulting treatment provider. Furthermore, I agree that the released parties have no liability or responsibility for the accuracy or completeness of the clinical information submitted to them or for any errors in its electronic transmission. I hereby Electronically sign and state that I have read, understood, and agree to the terms of this informed consent document.