Telemedicine Consultation Authorization and Consent

Instructions

We will be using a HIPAA compliant platform through https://doxy.me/ for your next office visit. Each visit we will determine if you need to use telemedicine or not. In order to have a telemedicine appointment, you will need a device (laptops, computers, tablet) with a camera and a microphone. Yes, your smart phone will work too! Just before (or even the morning of) your designated appointment time go to the appropriate link below and enter the waiting room. At your allotted appointment time your physician will activate the call on their end. (Bruneau) https://doxy.me/drbruneau1 (Lush) https://doxy.me/drlush (Nguyen) https://doxy.me/drvnguyen (Sinclair) https://doxy.me/nsnm (Zampiello) https://doxy.me/drzampiello For more specific instructions, please visit our website: https://www.northseattlenaturalmedicine.com/telemedicine

Purpose and Benefits

The purpose of this form is to obtain your consent to participate in telemedicine consultation with your doctor. The purpose of this project is to use telemedicine to enable patients living in rural and/or underserved areas to get medical care by specialists without the inconvenience and expense of traveling to a city.

Nature of Telemedicine Consultation

During the telemedicine consultation:

Details of your (or the patient’s) medical history, examinations, x-rays, and tests will be discussed with other health professionals through the use of interactive video, audio, and telecommunications technology.
Physical examination of you (or the patient) may take place.
Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission.
Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.

Medical Information and Records

All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized over existing confidentiality laws.

Confidentiality

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and Washington State law apply to information disclosed during this telemedicine consultation.

Risks and Consequences

The telemedicine consultation will be similar to a routine medical office visit, except interactive video technology will allow you to communicate with a physician at a distance. At first you may find it difficult or uncomfortable to communicate using video images. The use of video technology to deliver healthcare and educational services is a new technology and may not be equivalent to direct patient to physician contract. Following the telemedicine consultation, your physician may recommend a visit to a Hospital for further evaluation.

Rights

You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You would have the option to consult with the specialist in person if you travel to his or her location.

Financial Agreement

We will be billing your insurance on file for the visit. We cannot guarantee coverage from your insurance company for telemedicine. We recommend calling your insurance prior to confirm your telemedicine benefits.

I acknowledge that it is my responsibility to check my insurance coverage prior to visits for telemedicine. In the instance of no insurance, I will be offered a Time of Service discount to be paid directly after the visit, or I can be billed in full.

I understand that typing in my full legal name below substitutes as a written signature for this form and that it is my responsibility to contact North Seattle Natural Medicine if I wish to be sent a copy I can print, sign, and send back prior to 24 business hours before my appointment.

I have been advised of all potential risks, consequences, and benefits of telemedicine. My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.

Full Legal Name

Date of Birth

(Patient or Person Authorized to Give Consent)

Phone Number

Email field

Patient Name if Different from Person Authorized to Give Consent

Primary Doctor You See (Click and Select)

This consent form is for the entire clinic of North Seattle Natural Medicine, not this specific Doctor.

Your message will be encrypted and can only be read by North Seattle Natural Medicine.