FDL Telemedicine Consent

I understand that telemedicine is the use of electronic information and communication technology by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand my health care provider will determine whether the condition being diagnosed and/or treated is appropriate for a telemedicine encounter. I understand I can choose to stop telemedicine consult at any time.
I understand that:
• My health care professional and I will communicate by interactive video conferencing using a telehealth platform
• My health care professional will have access to all the clinical tools available at a regular office visit (e.g. prescription refills, appointment scheduling, patient education, etc)
• There are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties
• My health care information may be shared with other individuals for scheduling and billing purposes
• The laws that protect privacy and the confidentiality of medical information also applies to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit
By signing this form, I certify:
• That I have read or had this form read and/or had this form explained to me
• That I fully understand its contents including that risk and benefits of the procedure(s)
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction

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