The purpose of this form is to obtain your consent to participate in a telemedicine consultation in connection with the care provided to the person to which you are the guardian.
During the telemedicine consultation, medical history, examinations, x-rays, and tests will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology. A physical examination may take place. A non-medical technician may be present in the telemedicine studio to aid in the video transmission. Video, audio, and/or photo recordings may be taken of you during the procedure(s) or service(s)
All existing laws regarding access to medical information and copies of medical records apply to this telemedicine consultation. Please note, that not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.
Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telemedicine consultation.
You may withhold or withdraw consent to the telemedicine consultation at any time without affecting the right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled
You agree that any dispute arriving from the telemedicine consult will be resolved in Georgia and that Georgia law shall apply to all disputes.
You have been advised of all the potential risks, consequences, and benefits of telemedicine. The health care practitioner has discussed with you the information provided above. You have the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All questions have been answered, and you understand the written information provided above.