• SANDPOINT WOMEN’S HEALTH TELEMEDICINE CONSENT/REFUSAL FORM

    SANDPOINT WOMEN’S HEALTH TELEMEDICINE CONSENT/REFUSAL FORM

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  • 1. PURPOSE: The purpose of this form is to obtain your consent to participate in telemedicine consultations in connection with the following procedure(s) and/or services:

    2. DEFINITION OF TELEMEDICINE: The remote delivering of health care services via technology-assisted media. This includes a wide array of clinical services and various forms of technology. The technology includes, but it not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system, or other electronic means. The delivery method must be secured by two-way encryption to be considered secure. Synchronous (at the same time) secure video chatting is the preferred method of service delivery.

    3. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:

    a. Details of your medical history, examination, x-rays, digital imaging, and tests will be discussed with the patient and/or other health professionals through the use of interactive video, audio, and telecommunication technology.

    b. A physical examination of the patient may take place.

    c. Video, audio, and/or photo recordings may be taken of the patient during the  telemedicine session as part of patient charting and records.

    PATIENT RIGHTS: I understand that telemedicine also involves the communication of my medical/mental health information, both orally and visually, to my provider who may be within Idaho or outside of Idaho at the time of communication. I understand that I have the following rights with respect to telemedicine:

    1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment, nor risking the loss or withdrawal of any program benefit to which I would otherwise be entitled.

    2. The laws that protect the confidentiality of my medical and mental health information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my telemedicine appointment is confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence toward self and/or an ascertainable victim; and where I make my mental and emotional state an issue in a legal proceeding.

    3. RISKS: I understand that there are risks and consequences from telemedicine, including, but not limited to the possibility despite reasonable efforts on the part of my provider, that the transmissions of my medical and mental health information could be disrupted or distorted by technical failures; the transmission of my medical or mental health information could be interrupted by unauthorized persons; and/or limited ability to respond to emergencies. The offices of Sandpoint Women’s Health decrease the likelihood of interruptions. However, there are ways to minimize interruptions and maximize privacy and effectiveness. Your provider will take every precaution to ensure technologically secure and environmentally private sessions. As the patient, you are responsible for finding a private, quiet location where the sessions may be conducted. If it is determined that I would be better served by another form of service (e.g. face-to-face services), my provider will attempt to accommodate these services. Finally, I understand that there are potential risks and benefits associated with any form of medicine and that despite my efforts and the efforts of my provider, my condition may not improve.

  • IN CASE OF TECHNOLOGICAL FAILURE: I understand that during a telemedicine session we could encounter a technological failure. Difficulties with hardware, software, equipment, and/or services supplied by a third party may result in service interruptions. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, the provider will call me at the telephone number provided on your intake form. I will keep my phone near me for these purposes. If problems with connectivity persist, the session may be rescheduled. I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.

    EMERGENCY CONTACT: I understand my provider may contact my emergency contact and/or appropriate authorities in case of emergency.

  • , hereby consent to engaging in telemedicine

    phone/videoconferencing with Sandpoint Women’s Health. I understand that “telemedicine” includes the practice of healthcare delivery, diagnosis, consultation, treatment, transfer of medical health records and data, and education using interactive audio, video, or data communications.

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