I {patientName} agree to participate in the Dot Lake Village Telemedicine Clinic. I understand that my image and my Protected Health Information will be transmitted electronically through the videoconference(s) to physicians and other healthcare professionals for the purpose of providing medical diagnostic assessment and treatment services to me.
I understand that the transmissions are encrypted and the likelihood of this transmission being intercepted by unauthorized persons is extremely small but is a possibility. I understand that my personal image will not be disclosed and effort will be made to protect other identifying information from disclosure.
I understand that I can withdraw my permission for the videoconference any time prior to the videoconference. I also understand that I may interrupt the videoconference at any time. Withdrawing my consent or interrupting the videoconference will not have any negative impact on my ability to continue my care. I understand that I may still pursue consultation in person with a physician or other healthcare professional. I understand that if I interrupt the videoconference, the videoconference will be incomplete and the healthcare professionals involved in the videoconference will be unable to provide treatment or services to me at that time.
I understand that there are limits to Telemedicine technology and there is no guarantee that this Telemedicine session will eliminate the need for me to see a specialist in person in order to receive appropriate or additional treatment for my current condition.
I have read this document carefully and any questions I have asked about this consent have been answered to my satisfaction. I fully understand the terms of my consent to the release of Protected Health Information and to participate in Telemedicine videoconference(s).
This consent will remain effective one year from the date of signature.