1.     ELECTRONIC MAIL COMMUNICATIONS:

• I allow Recipients use electronic mail (e-mail) to communicate clinical information to me pertaining to services that I have received. I acknowledge and understand that e-mail communications may contain my personal and private medical information including, but not limited to, my name, address, date of birth, types and dates of health care services received, medications, and/or test results.

2.     VIDEOCONFERENCING COMMUNICATIONS:

• If available, I allow Recipients to use videoconferencing to communicate clinical information to me pertaining to services that I have received. I acknowledge and understand that videoconferencing communications may contain my personal and private medical information including, but not limited to, my name, address, date of birth, types and dates of health care services received, medications, and/or test results.

3.     TELEPHONIC COMMUNICATIONS:

• I allow Recipients to use telephone to communicate clinical information to me pertaining to services that I have received. I acknowledge and understand that telephone communications may contain my personal and private medical information including, but not limited to, my name, address, date of birth, types and dates of health care services received, medications, and/or test results.
• I allow Recipients to leave voicemail messages on answering machines or with individuals answering the phone at the number written in this section, including referral information, appointment reminders, test results, and other information that Recipients determine appropriate to leave on voicemail or with the person answering the phone.

4.     TEXT MESSAGE COMMUNICATIONS:

• I allow Recipients to send text messages to me at the number written in this section, including referral information, appointment reminders, test results, and other information that Recipients determine appropriate to send via text message.

5.     LIMITATIONS OF AND ACCESS TO COMMUNICATION DEVICES:

• I understand that although Recipients will attempt to protect the privacy of the contents of e-­mail communications, video conferencing, telephonic and text messaging communications sent to me and will take reasonable measures to keep my personal information confidential, the text messaging communications sent to me may not be encrypted at all times when at rest and in transit over the Internet. As a result, there is a risk that the e-­mail, videoconferencing, and text messaging communications may be intercepted and heard or read by unauthorized third parties. In allowing Recipients to communicate with me via text messaging communications, I assume these risks.
• E-­mail, Video Conferencing, and Text is not appropriate for conveying information relating to urgent or emergency medical matters. If I am experiencing an urgent or emergency situation, I understand that I should dial 911 immediately.
• I understand that it is my responsibility to make sure that only authorized people are allowed to access my email, telephone, computer, and mobile devices. If individuals other than me receive my protected health information delivered in the methods allowed on this form, those individuals may share it with others, and state and federal privacy laws will not protect it.

6.     TELEHEALTH EXPLANATION AND CONSENT.

I acknowledge and understand the following as it relates to telehealth:

• Telehealth is the use of electronic information and telecommunications (including videoconferencing) to support and promote long-­distance clinical healthcare, patient and professional health-­related education, public health and health administration. Telemedicine is sometimes distinguished from Telehealth as more narrowly applying to the practice of medicine from one clinical setting to another. Telehealth and Telemedicine are defined under certain state and federal laws to exclude communications through an audio only telephone, email messages, text messages, facsimile transmission, U.S. Mail or other parcel service, or any combination thereof. Telecommunications, including videoconferencing is not the same as direct visits between the patient and healthcare provider, as I will not be in the same room or location as the consulting provider. I understand if the consulting provider is located in another state or country, different laws may apply to the care I receive.
• Telehealth allows Recipients to provide educational services to me that may otherwise require me to travel long distances. I understand alternatives to telehealth consultation are available. I understand these services are solely informational and educational. No licensed medical professional/patient relationship is created by using or relying on information or advice provided by Recipients.
• My participation in any telehealth consultation is completely voluntary. I may revoke this Authorization if I decide to receive no further telehealth services. I understand Recipients are unable to take back any uses or disclosures they have already made prior to my revocation.
• Details of my medical history, including but not limited to insurance, treatment recommendations, pathology reports, test results, and radiology images if applicable (collectively “healthcare information”) may be shared electronically and discussed with a treating physician.
• Non-­medical personnel may be present to assist in operating telephone and/or videoconferencing equipment. I will be informed of any non-­medical personnel present during telephone and/or videoconference meetings.
• My healthcare information may be shared with other individuals for scheduling and billing purposes.
• Video, audio, and/or photo recordings may be taken during the meetings to aid in documenting the progress of your treatment. Recipients may keep a record of the consultation.
• Despite Recipients’ best efforts to protect the confidentiality of patient information, the security protocol could fail causing a breach of privacy of personal medical information.
• Information provided by telehealth to Recipients may be insufficient to allow for educational information to be provided.
• Potential risks to the use of this technology include delays in service, interruptions, unauthorized access, security breaches, and technical difficulties, all of which may occur due to failures of the electronic equipment, or other causes.
• The risks involved with Telehealth include the potential release of private information due to the complexities and abnormalities involved with the Internet. Viruses, Trojans, and other involuntary intrusions have the ability to grab and release information you may desire to keep private. Furthermore, there is the risk of being overheard by anyone near you if you do not place yourself in a private area and open to other’s intrusion.

7.     RELEASE OF LIABILITY:

• I further release and hold harmless Recipients and its respective owners, officers, employees, contractors, business associates and/or agents for any harm, claim, injury or damages of any kind including, but not limited to, compensatory, direct, indirect or consequential damage, directly or indirectly, as result of any and all uses of the services hereunder and any review, interpretation or analysis or and/or reliance on any and all Recipients.

8.     RE-­‐DISCLOSURE:

• Any health information about me may be re-­disclosed to others only to the extent permitted by state and federal laws and regulations. I understand that once my information is disclosed, it may be subject to lawful re-­disclosure, in accordance with applicable state and federal law, and in some cases, may no longer be protected by federal privacy law.