“TELEHEALTH” DEFINED
Telehealth is the delivery of healthcare services using technology when the healthcare provider and patient are not in the same physical location, and/or the virtual delivery of healthcare services, including by a medical provider or via digital or automated tools, including without limitation tools for medical or health-related diagnosis and treatment. The telehealth services may be used for diagnosis, treatment, care management, follow-up and/or patient education, and may include, without limitation, the following: electronic transmission of patient medical records, medical images, and/or other patient data or information; synchronous (i.e., "real time") and asynchronous (i.e., non-"real time") interactions via audio, video, text, and/or data or other electronic communications; automated, electronic or digital tools or services for diagnosis, care, treatment and/or communication pertaining to healthcare or medical matters; and output, transmission or exchange of data from medical devices, sound and video files.
PURPOSE OF CONSENT
I understand that my health care provider wishes to engage in a telehealth visit or series of visits, and my health care provider has determined such visit is an appropriate form of medical care at the current time. The treating health care practitioner intends the telehealth encounter to take the place of a face-to-face visit.
NATURE OF TELEHEALTH CONSULTATION
You consent to receive emails or other electronic communications from [Name of Entity] pertaining to your care and your health, which may include Protected Health Information. You understand that virtual encounters via phone, email, video, or otherwise, could involve, and you hereby consent to the use of, automated tools for diagnosis, care, treatment or communication pertaining to healthcare matters. You also acknowledge that such virtual encounters may involve care by a variety of Providers, including Physicians, Registered Nurses, Nurse Practitioners, Physician Assistants, Nutritionists, Naturopathic Doctors, Therapists, and other support or medical personnel.
RISKSOF TELEHEALTH SERVICES
You understand that your condition may not be treated via the telehealth or that information transmitted through telehealth may not be sufficient or of too poor of image quality, or insufficient information or data to allow for appropriate medical decision making. Accordingly, you may be required to seek additional in-person medical care, alternative healthcare or emergency services. If your health or medical problem or condition persists after use of telehealth services, you agree to immediately contact your medical services provider and seek appropriate additional in-person medical care or emergency care, as appropriate. Additionally, you understand security protocols could fail in rare circumstances causing a breach of patient privacy.
PERSONAL HEALTH INFORMATION AND MEDICAL RECORDS
In all circumstances, health care providers will abide by federal and California privacy laws, including not disclosing your personal health information to any third party without written consent. You understand your health care provider will document all personal health information into your medical records provided during your telehealth encounter
PATIENT RIGHTS
You have the option to refuse telehealth services or revoke your consent at anytime without affecting your right to receive future care or treatment. In situations when the asynchronous store and forward system is used, you must be notified of your right to have interactive communication with the distant specialist at the time of the consultation or within 30 days of notification of the results of the consultation.
FINANCIAL RESPONSIBILITY
You are responsible for all charges not covered by any insurer or third party payor, including any deducible or co-payments, or any charges not covered as a result of your failure to provide notification to obtain prior authorization as required by any insurer or third party payor.
VALIDITY OF CONSENT
Your consent under this form is indefinite unless otherwise revoked or amended, or is no longer effective under appliable law.
My health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I have read and agreed to receive telehealth services.
Name of User :
