1.     I hereby authorize Telemedora, PC to use a telehealth platform for telecommunication for evaluating, testing and diagnosing my medical condition.
2.     I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
3.     I understand and agree that the professionals can conduct interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
4.     I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.
5.     I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
6.     I understand and agree that:
·       I will not be in the same location or room as my physician.
·       My Telemedora, PC physician is licensed in the state in which I am receiving services. I will report my location accurately during registration.
·       Potential benefits of telehealth (which are not guaranteed or assured) include: (i) More efficient medical evaluation and management; and (ii) During the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
·       Potential risks of telehealth include: (i) Limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my physician in diagnosis and treatment; (ii)My Physician’s inability to conduct a hands-on physical examination of me and my condition; and (iii) Delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Telemedora, PC, its physicians or employees, responsible for lost information due to technological failures.
·       I further understand that my Telemedora, PC physician’s advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my Telemedora, PC physician relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
·       I may discuss the risk, benefits of medical treatment and its alternatives with my Telemedora, PC physician and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by Telemedora, PC.
·       I understand that the level of care provided by my Telemedora, PC physician is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.
·       I have the right to receive face-to-face medical services at any time by traveling to a medical center that is convenient to me.
·       In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.