I understand that telemedicine is the use of electronic information and communication technology by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand my health care provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter. I understand I can choose to stop the telemedicine consult at any time. Due to the rapidly evolving reimbursement guidelines during the Covid-19 outbreak, I understand that this visit will be submitted to insurance for payment, just as a normal in-person appointment would be. Co-pay may be collected.
I understand that:
My health care professional and I will communicate by interactive video conferencing using a telehealth platform.
My health care professional will have access to all the clinical tools available at a regular office visit. (e.g. prescription refills, appointment scheduling, patient education, etc.) However, diagnostic and therapeutic tools such as biopsy, cryotherapy, dermoscopy, uniform lighting are not available during telehealth visits.
The Telehealth platform may ask for vital signs. I understand I will enter height in feet and inches, weight in pounds, blood pressure, temperature, and pulse rate.
There are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. During this COVID crisis, the government is allowing platforms that may not be HIPPA compliant. I understand that there is a risk that my telehealth video information and/or images I email to your clinic may not be HIPPA compliant. All documentation will be HIPPA compliant.
My healthcare information may be shared with other individuals for scheduling and billing purposes.
The laws that protect the privacy and the confidentiality of medical information also applies to telemedicine. However, as above, the video platform may not be HIPPA compliant and there is a risk of loss of privacy.
By signing this form, I certify
That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.