1. I understand that my health care provider, Dynamic Home Therapy (“Dynamic”), wishes me to engage in a telehealth consultation and treatment 

2. Dynamic has explained to me the limitations of utilizing  video conferencing technology to effect such a consultation, including the limitations posed by the fact that I will not be in the same room as my health care provider. 

3. I understand that the telehealth platform that Dynamic uses is Zoom.  While this platform is designed to be effective and HIPAA-compliant, I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that Dynamic or I may discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. 

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes as described more thoroughly in Dynamic’s Notice of Privacy Practices, which I have received, have reviewed and understand. 

5.  I understand that other members of Dynamic’s staff may also be present during the consultation other than my Dynamic practitioner(s) as necessary to operate the video equipment. I further understand that such additional staff are under an obligation to maintain confidentiality of the information obtained or discussed. 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. 

6. Dynamic has explained to me the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals/family/caregivers at my location at the direction of the consulting health care provider. 

7. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection. 

8. I understand that billing will occur from my practitioner from Dynamic. 

9. I have had a direct conversation with my Dynamic practitioner, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. 

By signing this form, I certify that: 

• I have read or had this form read and/or had this form explained to me;

• I fully understand its contents including the risks and benefits of the procedure(s); and 

• I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction, and that I can call my healthcare provider at any time with more questions.

Based on the foregoing, I hereby consent to receiving the one or more telemedicine consultations and treatment from Dynamic.