Consent for Telemedicine Services

INFORMED CONSENT FOR TELEMEDICINE

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.

The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and video, Output data from medical devices and sound and video files

Expected Benefits:

Improved access to medical care by enabling a patient to remain at their home while the provider is at their remote location.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
-A limited exam as opposed to an in person evaluation.
-In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
-Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
-In rare instances, security protocols could fail, causing a breach of privacy of personal medical information

By Signing This Form, I Understand The Following:

1) I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2) I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3) I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
4) I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My physician has explained the alternatives to my satisfaction.
5) I understand that it is my duty to inform my physician of electronic interactions regarding my care that I may have with other healthcare providers.
6) I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
I hereby give my informed consent for the use of telemedicine in my medical care. I hereby authorize the physicians at Just for Kids Pediatrics, PLLC to use telemedicine in the course of my diagnosis and treatment.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.