Informed Consent for Telehealth Visits

Information About Telehealth:

Telehealth 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. Providers may include primary care practitioners, specialists, and/or subspecialists. 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

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient information, and will include measures to safeguard and ensure the integrity of any transmitted data.

Expected Benefits:

There are many potential benefits to telehealth, including the following:

• Improved access to medical care by enabling you to remain at a remote site, such as your home or your physician’s office, while still receiving medical care
• Access to medical providers that may not be available in your geographic area
• Improved ability for your physician to obtain information from other providers, such as test results and specialty opinions
• More efficient medical evaluation and management

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

• The inability to perform certain aspects of a physical examination or evaluation.
• Insufficient information (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 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 result in adverse drug interactions or allergic reactions or other judgment errors;

By signing this form, I understand the following:

1. The laws that protect privacy and the confidentiality of medical information also apply to telehealth, and no information obtained in the use of telehealth which identifies me will be disclosed to researchers or other entities without my consent.
2. I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.
3. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
4. Alternative methods of medical care have been explained to my satisfaction. I understand that I may choose an alternative method of care, including in-person care, at any time I wish after proceeding with telehealth.
5. Telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. There are risks inherent to telehealth, including but not limited to those risks explained above.
7. While there are anticipated benefits from the use of telehealth in my care, results cannot be guaranteed or assured.

Patient Consent for the Use of Telehealth

I have read and understand the information provided above regarding telehealth, have discussed it with my physician or their designee, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical care.

I hereby authorize Michelle Randolph MD to use telehealth in the course of my diagnosis and treatment.

Disclaimer: 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.