Consent to Participate in Telemedicine

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.