Telehealth Consent

Please correct the errors described below.

What It Is

Telehealth services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

Examples of telehealth that can be charged to your insurance:

-Televisits- The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home. These visits are considered the same as in-person visits. The coinsurance and deductible would generally apply to these services.

-E-visits- In all types of locations including the patient’s home, and in all areas (not just rural), established patients may have non-face-to-facepatient-initiated communications with their doctors without going to the doctor’s office by using online patient portals.

-Virtual visits- In all areas (not just rural), established patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image.


I understand that Rheumatology Center Of Houston is offering telehealth services as an adjunct to the standard office visits.

I understand that the same standard of care applies to a teleheatlh visit as applies to an in-person visit. I understand that I will not be physically in the same room as my health care provider. I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.

I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.

If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

I understand that a limited physical examination will take place during the videoconference and that I have the right to ask my healthcare provider to discontinue the conference at any time. I understand that some parts of the exam may be conducted by individuals at my location at the direction of the consulting health care provider.

I understand that with telehealth visits, delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

In rare cases, a lack of access to complete medical records may results in adverse drug interactions or allergic reactions or other judgement errors.

In addition to televisits used at times in place of office visits, my provider at Rheumatology Center Of Houston may also use the telephone or patient portal to address my issues. I understand a fee may apply for certain telephone visits with the provider.

I understand that I have the right to refuse to participate or decide to stop participating in a telehealth visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

I may revoke my right at any time in writing, forwarded to Rheumatology Center Of Houston at fax 713-640-5872 or 1200 Binz St Ste 1495Houston, TX 77004.

I understand that the laws that protect privacy and the confidentiality of health care information apply to telehealth services.

I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

I understand that my insurance carrier will have access to my medical records for quality review/audit.

I understand that this document will become a part of my medical record.

I hereby release Rheumatology Center Of Houston, its personnel and any other person participating in my care from any and all liability which may arise from the taking and authorized use of such videotapes, digital recording films and photographs.

Financial Responsibility

I understand that I will be responsible for any out-of-pocket cost such as copayments or coinsurances that apply to my telehealth visit.

I agree to pay, in a timely manner, for telehealth services. I authorize payments directly to Rheumatology Center Of Houston for all benefitspayable. I understand that I am fully responsible for any unpaid bills not covered by my insurance.

By signing this form, I attest that I (1) have personally read the Telehealth Consent (or had it explained tome) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telehealth visits shared with me in a language I understand.

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

Telehealth Consent will be submitted to Rheumatology Center Of Houston

Your information will be encrypted.