1. Purpose.
The purpose of this form is to get your consent for a telehealth visit with your dermatology provider at Jason B. Amato, MD Dermatology. The purpose of this visit is to help in the care of your skin problem.
2. How Telehealth Works.
In a telehealth visit, you will interact in real time with your dermatology provider via secure, online videoconferencing technology. Your dermatologist has the right to discontinue or not provide a consult via videoconference should the videoconference connection be of poor quality. You may be required to make an in-person appointment for further evaluation should this occur. The provider will look at the patient's skin during a videoconference. The provider will then give you advice about your dermatologic condition and how to treat and take care of your condition. The information from the dermatologist may not be the same as a face-to-face visit, because the dermatologist is not in the same room.
3. Pros, Cons and Your Options.
With telehealth, a dermatologist will advise you based on viewing your condition during a videoconference. Sometimes a face-to-face follow-up visit with the dermatologist may still be needed. If you do not come into the office for an in-person visit, the dermatologist's advice will be solely based on viewing your skin condition during a videoconference. In the absence of an in-person physical evaluation, the dermatologist may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of your condition and recommended treatment. It is possible that there will be deficiencies in the videoconference that may impede the dermatologist's ability to advise you about your condition. Also, very rarely, secutity measures can fail to protect your personal information, but the company that is providing the technology for your telehealth visit has extensive security measures in place to prevent such failures from happening.
4. Presence of Others During Telehealth Visit.
People other than your doctor may be a part of the patient's care and present during a telehealth visit. These people may be resident doctors (who have finished medical school and are now completing an "on-the'job" training in the office), medical students, or nurses. Anyone that is part of the telehealth team will be supervised by the provider, and the final recommendations abou your care will come from the provider. Also, non-medical people may help to set up the telehealth equipment. You may ask for persons other than your dermatologist to leave the room if you are uncomfortable having them participate in your telehealth visit.
5. Medical Information and Records.
All federal and state laws covering access to your medical records (and copies of medical records) also apply to telehealth. No one other than the health care team described above can view your information unless you agree to give them access.
6. Privacy.
All information given at your telehealth visit will be maintained by the doctors, other health care providers, and health care facilities involved in your care and will be protected by federal and state privacy laws.
7. Your Rights.
You may opt out of a telehealth visit at any time. This will not change your right to future care or health benefits.
8. Waiver/Release.
By signing below, you understand and agree that you solely assume the risk of any errors or deficiencies in the electronic transmission of information during your telehealth visit and further understand that no warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis. To the extent permitted by law, you also agree to waive and release your dermatologist and his or her institution or practice from any claims you may have about this advice or the telehealth visit generally. The consent provided in this document will expire in one year from the date you sign it, but your waiver and release shall apply indefinitely for any telehealth visits that occur during the one-year period after your signature date.