1. PURPOSE: The purpose of this form is to obtain your consent for a telemedicine consultation with a physician and/or healthcare provider. The purpose of this consultation is to assist in the diagnosis or treatment of your dermatology related condition.
2. NATURE OF TELEMEDICINE CONSULTATION: Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio and telecommunication technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken. Additionally, non-medical technical personnel may participate in the telemedicine consultation to aid in the audio/video link with the physician.
3. RISKS, BENEFITS AND ALTERNATIVES: The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.
4. MEDICAL INFORMATION AND RECORDS: All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.
5. CONFIDENTIALITY: All existing confidentiality protections under federal and California law apply to information used or disclosed during your telemedicine consultation.
6. RIGHTS: You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. If you are a Medi-Cal recipient and receiving teleophthalmology or teledermatology by store and forward, you have the right to interactive communication with the physician. This communication may occur at the time of your consultation or within 30 days after you receive the results of the consultation.
My health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I have read and agreed to a telemedicine consultation.