I authorize Planet Vision Eyecare providers to perform a Telehealth consultation and provide me with their observations and recommendations regarding my medical condition and potential courses of action. The use of Telehealth involves the electronic communication of my medical information with the use of a secure synchronous video conferencing platform. I understand that Planet Vision Eyecare is a Telehealth technology provider based in Florida and when performing such a consultation, the providers will not be performing an in-person physical examination. They will rely solely on the information telecommunicated. I authorize the Planet Vision Eyecare provider to consult with any other physician specialists whom they may choose to involve in my case if necessary.

I understand that I have the following rights with respect to the Telehealth services performed by Planet Vision Eyecare:

1. Right to Withdraw. I have the right to withhold or withdraw my consent to Telehealth at any time, without effecting my future right to health care or treatment and without risking the loss of my health coverage.

2. Access to Information. I have the right to inspect all medical information transmitted during Planet Vision Eyecare’s Telehealth consultation, and may receive copies of this information for a reasonable fee. 

3. Confidentiality. The laws that protect the privacy and confidentiality of medical information apply to Telehealth, and no information or images obtained from the Telehealth interaction which identify me will be disclosed to researchers or other entities without my consent, except as permitted by law.

4. Alternative Methods. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My physician has explained the alternatives to my satisfaction.

5. Electronic Communication. I understand that 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.

6 Other Electronic Interactions. I understand that it is my duty to inform my physician of electronic interactions regarding my care that I may have with other healthcare providers.

7. Guarantees and Assurances. I understand that I may expect the anticipated benefits from the use of Telehealth in my care, but that no results can be guaranteed or assured.

I understand that there are risks from Telehealth, including but not limited to: power failure with loss of communication; insufficient transmission of information (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); in rare cases, loss of records from failure of electronic equipment; in rare cases, a lack of access to complete medical records which may result in adverse drug interactions or allergic reactions or other judgment errors; in very rare instances, security protocols could fail with invasion of electronic records from outsiders (hackers) causing a breach of privacy of personal medical information. In addition, signs and symptoms that might be detected during an in-person physical examination may not be detected through Telehealth. I understand that I have the option of seeing another physician on a face to face basis who could provide me with observations and recommendations.

I warrant that the Planet Vision Eyecare provider/physician observations and recommendations are limited in scope and nature to the specific issues discussed during the Telehealth consult.

I have read and understand the information provided above. I agree and all my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telehealth in my medical care.