Informed Consent

Informed Consent for Telehealth Consultations

To better serve the needs of people in the community, health care services are now available by interactive video or phone communications and/or by the electronic transmission of information. 

This may assist in the evaluation, diagnosis, management and treatment of a number of health care problems. This process is referred to as “telemedicine” or “telehealth.” This means that you may be evaluated and treated by a health care provider or specialist from a distant location. Since this may be different than the type of consultation with which you are familiar, it is important that you understand and agree to the following statements. 

  1. The consulting health care provider or specialist will be at a different location from me. 
  2. The practitioner may transmit or share electronically details of my medical history, examinations, x-rays, tests, photographs or other images at my direction to different location. 
  3. I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, the presenting practitioner. I will give my verbal permission prior to the entry of the additional personnel into the conversation whether by phone or video. 
  4. RELEASE OF INFORMATION: Physicians who provide professional services to the patient are authorized to furnish medical information from my medical record to a referring physician, if any, and to any insurance company or third party payer for the purpose of obtaining payment of the account. The physician is authorized to release information from my medical record to any other health care facility or provider to which my care may be transferred. 
  5. I voluntarily consent to health care services provided by my doctor(s) or a designee, which may include diagnostic tests, drugs, examinations, and medical treatments considered necessary. 
  6. I understand that it is my responsibility to decide follow-up care and make appropriate arrangements. 
  7. I agree that I am ultimately responsible for the payment of the account and the provider will furnish the proper medical invoice to present to any payor of choice for reimbursement. 
  8. I understand that I have the option to refuse telehealth service at any time without affecting the right to future care or treatments.