Consent for Telehealth Services

Definition of Telehealth

Telehealth involves the use of electronic communication to enable you, the patient, to share and discuss medical information with a provider for the purpose of delivering convenient, efficient, and effective patient care. Telehealth includes the practice of health care delivery, diagnosis, consultation, referral to resources, education, and the transfer of medical and clinical data.

Your Rights with Respect to Telehealth

• The laws that protect privacy and confidentiality of medical information also apply to telehealth, so any consultation via telehealth is secure and 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 an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I understand that my healthcare information may be shared with other individuals for scheduling and billing and insurance purposes. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.
• I understand that these telehealth conferences are not routinely recorded. However, there may be instances in which the health care provider may need to obtain a photograph or video or audio recording. By signing below, I grant permission to my telehealth providers to photograph, videotape, and/or audiotape me and to use such photographs, videotape and/or audiotape for clinical, educational, and legal purposes.
• I understand that I may decline to receive medical services by telemedicine and may withhold or withdraw my consent from such care at any time without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting my healthcare provider. As long as this consent is in force (has not been revoked), my healthcare team may provide healthcare services to me via telehealth without the need for me to sign another consent form.
• I understand that I have a right to access my medical information and copies of my medical records in accordance with the laws pertaining to the State in which I reside.
• I have been provided with a copy of the provider's Notice of Privacy Practices. An online version of this notice can be found at https://www.yourera.com/privacy.

Potential Risks and Consequences Regarding Telehealth

I understand the following concerning telehealth consultations:

• Videoconferencing equipment could fail, causing delays in medical evaluation and treatment.
• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the consulting provider.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
• I understand that if my telehealth provider believes I would be better served by another form of intervention (e.g., face-to-face services), I could be referred to another health professional.

Use of Telehealth Technology

• It has been explained to me how videoconferencing technology will be used to facilitate the consultation since the consulting provider and I will not be in the same room.
• Individuals may be present with the consulting provider to operate equipment or to assist with evaluation, examination and/or treatment. I will be told if there are other people present. I have the right to: (1) omit specific details of my medical history that are personally sensitive to me, (2) ask non-medical personnel to leave the room; and/or (3) stop the consultation at any time.
• If my telehealth consultation is not able to be completed for any reason (such as equipment failure), I may work with the provider/personnel to reschedule.
• I understand that the provider will bill my insurance or Medicare for these services. I understand that I may be responsible for payment of services, copayment or coinsurance if required by my insurance company.
• I understand telehealth services should never be used for urgent matters. If I need care emergently, I will either call 911 or go to the nearest emergency room without delay.

Alternatives to Telehealth

• The alternatives to a telehealth consultation have been explained to me, and I have chosen to participate in a telehealth consultation.

Benefits of Telehealth

• I understand I may expect anticipated benefits from the use of telehealth in my care, such as improved access to care and more efficient evaluation and management, but that no results can be guaranteed or assured.

I have read this document carefully and understand the risks and benefits related to the use of telehealth services and have had my questions regarding the use of telehealth explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.