Disclosure and Consent On Telemedicine
I have voluntarily requested and gave permission (consent) to provide me
medical and/or health care through telemedicine technology and services.
I understand that during consultation my consultant
may:
- Conduct his practice and medical care in a
different location than the one where I may be physically present.
- Not have the opportunity to perform an
in-person physical exam of me at the time my telemedicine services are
provided.
- Rely on information given by me before and
during our telemedicine services appointment.
I understand that I must provide information to the
best of my knowledge and ability that is complete and accurate. This includes
information about my medical history, condition(s), and current or previous
medical care.
I understand that my consultant’s advice,
recommendations, and/or decisions may be based on factors not within their
control, such as incomplete or inaccurate data provided by me or the
distortions of diagnostic images or specimen due to electronic transmission
issues.
I understand that if telemedicine services are
interrupted due to a technology problem or equipment failure or other reason, a
different way of communication may need to be used and/or I may need to have an
in-person medical evaluation with a health care provider located in my area.
I understand that the level of care provided by my
consultant is to be the same level of care that is available to me through an
in-person medical visit. If my consultant determine that the telemedicine
services will not adequately address my medical needs, the consultant may
require me to schedule and attend an in-person appointment with my health care
provider.
I understand that if I experience any urgent
medical symptom(s) or condition(s) after a telemedicine session, I should go
directly to the nearest emergency room.
I understand that I am responsible for any
copayment or deductible amounts associated with telemedicine visits, in
accordance with my insurance company’s policies. If my insurance company does
not cover telemedicine visits, I understand I am financially responsible for
the cost of such visits.
I have been given an opportunity to ask questions
about the telemedicine services to be provided to me. I understand the risks
and hazards involved with telemedicine services. I believe that I have enough
information to give informed consent to receive telemedicine services by my
consultant.
1 Comments
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