Telehealth Informed Consent

I understand that telehealth is "a mode of delivering health care services, via communication technologies (e.g. Internet or video phone call) to facilitate diagnosis, consultation, treatment, education, care management, and self-management." I understand that telehealth involves the use of electronic communications to enable health care providers to deliver care at a distance. I understand that the following conditions apply to telehealth:

No Guarantees

The results of this consultation are not guaranteed or assured. As with any medical procedure, there are potential risks associated with the use of telehealth.

In-Person Visits Preferred

Telehealth is not a replacement for in-person medical evaluation. Your physician may determine that an in-person visit is necessary.

Confidentiality

The laws that protect the confidentiality of medical information also apply to telehealth. Your telehealth visit will be conducted in a private setting.

Risks

• Information transmitted may not be sufficient for appropriate medical decision-making
• Delays in evaluation and treatment could occur due to failures of electronic equipment
• Security protocols could fail, causing a breach of privacy
• Lack of access to complete medical records may result in adverse drug interactions or allergic reactions
• A face-to-face meeting with your provider may be needed
• Your physician may record sessions for visit documentation purposes

Identity Verification

You will be asked to verify your identity at the beginning of each telehealth session.

Fees & Billing

You are responsible for all co-pays, deductibles, and coinsurance that apply to your telehealth visit, just as you would be for an in-person visit.