Consent for Telemedicine
Introduction: Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time. Consent for Treatment: I voluntarily request Annapolis Rheumatology to participate in my medical care through the use of telemedicine. I understand that my Doctors at Annapolis Rheumatology (a) may not have the opportunity to perform an in-person physical examination, and (b) rely on information provided by me. I acknowledge that the Doctors advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure. If the doctors at Annapolis Rheumatology determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies I will dial 911, or go to the nearest hospital emergency department. Release of Information: To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my medical record (including oral information) to Annapolis Rheumatology. I understand and agree that the information I am authorizing to be released may include: 1) blood test results, diagnosis, treatment, and related information: 2) drug screen results and information about drug and alcohol use and treatment; 3) mental health information; and 4) genetic information. I understand that the disclosure of my medical information to Annapolis Rheumatology, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering. Assignment of Benefits: I hereby certify that all of the information that is provided in this form is complete and accurate. I understand that the healthcare services rendered may not be covered by or may indeed exceed all of my plan benefits. I also understand that I alone am financially responsible to the service provider for all of the cost that is associated and I do hereby assign my benefits payable to the above-named service provider and I authorized payment directly to them. I request that payment of authorized medical benefits is made on my behalf directly to Annapolis Rheumatology LLC, for service(s) furnished to me. I authorize the release of any medical information to my health insurance carrier and/or its legitimate agents that is necessary to process related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards. I authorize payment of service(s), otherwise payable to me under the terms of my private, group employer’s or group health insurance plan, directly to Annapolis Rheumatology LLC. I hereby authorize that photocopies of this form are valid as the original. Privacy Notice: By signing below, I acknowledge that I have received the practice's Notice of Privacy Practices. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices. The Privacy Policies can be found online at www.arheum.com or available at the Practice location. I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.
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