Consent To Telehelth

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for examination, treatment, diagnosis, and/or follow-up, and may include any of the following:
Patient medical records
Medical images
Live two-way audio and video
Output data from medical devices and sound and video files
Files related to my health information
Electronic systems used incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits:
Improved access to medical care by enabling a patient to remain in his or her home, physician’s office or at a remote site while the physician obtains test results and consults from healthcare practitioners at distant sites.
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.
Possible Risks:
As with any medical procedure, 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 (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and/or other healthcare providers.
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
Security protocols could fail, causing a breach of privacy of personal medical information.
By signing this form, I understand the following:
The laws that protect the privacy and confidentiality of medical information also apply to telehealth.
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.
I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.
A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My healthcare provider has explained the alternatives to my satisfaction.
Telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
It is my duty to inform my healthcare provider of interactions regarding my care that I may have with other healthcare providers.
I may expect the anticipated benefits from the use of telehealth in my care, but no results can be guaranteed or assured.
I have a right to receive a copy of this consent form.
Patient Consent To The Use of Telehealth
I have read and understand the information provided above regarding telehealth. I hereby give my informed consent for the use of telehealth in my medical care.
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