Health care services are available by two-way interactive video communications and by the electronic transmission of information. Referred to as “telemedicine”, this means that I may be evaluated and treated by a health care provider from a different location. Since this is different than the type of consultation with which I am familiar, if I choose to participate in this type of service, I understand and agree to the following:
1. The health care provider will be at a different location from me.
2. I will be informed if any additional personnel are to be present other than myself and any individuals accompanying me. I will give my verbal permission prior to additional personnel being present.
3. Video recordings may be taken of the telemedicine consultation after I have given my written permission prior to recording. Video recording and other data including images and photos may be kept, viewed, and used for purposes including teaching, training, technically, scientific, research, or administrative purposes.
Noting all the above, I understand that my participation in the process described (called “telemedicine”) is voluntary and constitutes a waiver of the usual right to patient privacy and may possibly increase the risk of disclosure of my medical or mental health data.
I further understand that I have the right to:
1.Refuse the telemedicine consultation or stop participation in the telemedicine consultation at any time. 2.Request that the health care provider refrains from transmitting my information if I make the request before the information is transmitted. 3.Request that nonmedical personnel leave the room at any time. I acknowledge that the health care provider involved explained the consultation in a satisfactory manner and that all questions that I have asked about the consultation have been answered in a manner satisfactory to me or my representative. Understanding the above, I consent to the telemedicine process described above.
This agreement will remain in effect for one year.