Telehealth Informed Consent
Telehealth is the practice of healthcare using electronic communication or other information technology when you and your healthcare provider are in different locations. Generally, healthcare providers can only treat patients who are physically located in the state where the provider is licensed. In some cases, healthcare providers can treat patients who are in-state residents, but are temporarily located out-of-state (e.g., on vacation Telehealth communications may include e-mail, facsimile, SMS/text/instant messaging, telephone, and video conferencing, and may be used on a variety of telephonic or electronic devices (collectively, "Communications") Your signature memorializes your informed consent and authorization for Practice and its providers to use Telehealth in the course of your care. By signing this Informed Consent and/or the underlying agreement, you acknowledge and understand the risks and benefits of receiving Telehealth, and you agree to the following terms
a. Telehealth should never be used in an emergency or urgent care situation. If you experience a medical or psychiatric emergency you must immediately call 911 or your local emergency department. You must seek urgent care when you need it and you must not rely on Telehealth for urgent health needs. If you prefer in-person appointments instead of Telehealth, please tell your provider and Practice will accommodate your request, or refer you to another provider. Declining to receive Telehealth on a specific occasion will not impact your access to Telehealth in the future.
b.Your provider has absolute discretion, at all times, to determine the suitability of delivering Telehealth. If your provider determines that a different form of healthcare services is appropriate (e.g., an in-person office visit), then your provider may discontinue Telehealth and will provide instructions and/or referrals for you to receive the recommended care.
c. Telehealth has certain benefits, but it also has certain limitations and risks. In some cases, transmitted information may be in sufficient to allow for appropriate healthcare decision-making by your provider (e.g., poor image resolution If your provider does not have access to information that would be apparent or available in a face-to-face visit, the use of Telehealth may result in medical error or misjudgment. Delays can result from equipment deficiencies or failures. No results can be guaranteed and you are always free to seek a second opinion. Telehealth never limits your ability to seek in-person care.
d. At each Telehealth session you must be physically located in the state in which your provider is licensed. If you are temporarily out-of-state, but maintain in-state residency, you must notify your provider before a Telehealth session commences. You provider may not be able to issue prescriptions, referrals, or other orders if you are out-of-state. You may need to seek local care for these and other healthcare needs.
e. You will cooperate with your provider at each session to assess the suitability