Informed Consent for Telemedicine Services
I understand that telemedicine is the use of electronic information and
communication technologies by a healthcare provider used to deliver services to an
individual when he/she is located at a different location or site than I am.
I understand that the telemedicine visit will be done through a two-way video
link-up. The healthcare provider will be able to see my image on the screen and hear
my voice. I will be able to hear and see the healthcare provider.
I understand that the laws that protect privacy and the confidentiality of medical
information including (HIPAA) also apply to telemedicine.
I understand that I will be responsible for any copayments or coinsurances that
apply to my telemedicine visit.
I understand that I have the right to withhold or withdraw my consent to the use of
telemedicine in the course of my care at any time, without effecting my right to
future care or treatment.
I understand that by signing this form that I am consenting to receive health care
services via telemedicine.
Signature of Patient, Guardian, or Legal Representative
Date Signed
-
Month
-
Day
Year
Date
Printed Name
Submit
Should be Empty: