CONSENT TO TELEHEALTH VISIT

Please correct the errors described below.

1. HOW TELEHEALTH WORKS

You will interact in real-time with your dermatologist via a secure, online teleconferencing application. Alternatively, you may be asked to submit photos and chief complaint via secure electronic messaging. Your dermatologist has the right to discontinue or not provide a consult should the videoconference connection or images be of poor quality. You may be required to make an in-person appointment for further evaluation. Your dermatologist can look at your skin during the video-conference or by way of photos submitted and will give you advice about your dermatologic condition and how to treat and take care of your condition. The information from the dermatologist will not be the same as a face-to-face visit because the dermatologist is not in the same room. Your insurance will be billed for the telehealth visit and you will be required to pay any deductible or copay. If you do not have insurance, you will be required to pay the cost of the visit.

2. PROS, CONS, AND YOUR OPTIONS

With telehealth, a dermatologist will advise you based on viewing your condition during a videoconference or submitted photos. Sometimes a face-to-face follow up will be needed. If you do not come into the office for an in-person visit, the dermatologist’s advice will be solely based on viewing your skin during a videoconference or on the information and images provided electronically. In the absence of an in-person physical evaluation, the dermatologist may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of your condition and recommended treatment. It is possible that there will be errors or deficiencies in the transmission of the images of your skin during the video-conference or in the photos submitted that may impede the dermatologist’s ability to advise you about your condition. Also, very rarely, security measures can fail to protect your personal information, but the technologies used for this visit have extensive security measures in place to prevent such failures from happening

3. PRESENCE OF OTHERS DURING TELEHEALTH VISIT

People other than your doctor may be a part of your care during the telehealth visit, such as medical assistants and non-medical people assisting with the telehealth visit. These people are supervised by the dermatologist and the final recommendations will come from the dermatologist. You may request that other people leave the room if you are uncomfortable having them participate in your visit.

4. MEDICAL INFORMATION, RECORDS, PRIVACY, AND YOUR RIGHTS

All federal and state laws covering access to your medical records (and copies of them) also apply to telehealth. No one other than the health care team described above can view your photos or information unless you agree to give them access. All information given at your telehealth visit will be maintained by the doctors, other health care providers, and health care facilities involved in your care and will be protected by federal and state privacy laws. You may opt-out of the telehealth visit at any time. This will not change your future care or benefits.

5. WAIVER/RELEASE

By signing below, you understand and agree that you solely assume the risk of any errors or deficiencies in the electronic transmission of information during your telehealth visit or in the electronic submission of your images to your dermatologist and further understand that no warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis. To the extent permitted by law, you also agree to waive and release your dermatologist and Southeast Dermatology from any claims you may have about this advice or telehealth visit generally. The consent provided in this document will expire in one year from the date you sign it, but your waiver and release shall apply indefinitely for any telehealth visits that occur during the one-year period after your signature date.

My doctor and/or representative talked with me about the telehealth visit. I have had a chance to ask questions and all my questions have been answered. I have read this form, understand the risks and benefits of the telehealth visit, and agree to a telehealth visit under the terms explained above.

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.

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