Informed Consent for Telemedicine Services

• I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different location or site than I am, and I must be physically located in the state of Colorado when receiving this service through Family Practice Associates.
• I understand the potential limitations of telemedicine, and that services will be provided to the best ability of the healthcare provider.
• I understand that Family Practice Associates utilizes the Hippo Health software program to conduct telemedicine services, and I agree to installing this application (app) on my cell phone, computer and/or tablet in order to receive telemedicine.
• I understand that the telemedicine visit will be performed through a two-way video link-up. The healthcare provider will be able to see my image on my cell phone screen, computer monitor or tablet, and the provider will hear my voice. I will be able to hear and see the healthcare provider.
• I understand that technical difficulties may occur before or during the telemedicine session, and that the healthcare provider may conduct the appointment via regular telephone communication if such difficulties interfere with utilizing Hippo Health.
• I understand the the laws that protect privacy and the confidentiality of medical information, including HIPAA, also apply to telemedicine.
• I understand that I will be responsible for any copayments or other financial patient responsibility, and that I am responsible for knowing whether my insurance plan covers telemedicine.
• I understand that by signing this form that I am consenting to receive health care services via telemedicine.

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.