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Authorization and Consent to Participate in Telemedicine/Telehealth Consultation

The purpose of this form is to obtain your consent to participate in a telemedicine consultation with a provider.

1) Nature of Telemedicine Consultation: During the telemedicine consultation: a) Details of you and/or your medical history, examinations, and laboratory tests will be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. b) Physical examination of you may take place. c) Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission. d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.

2) 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 under existing confidentiality laws.

3) 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 state law apply to information disclosed during this telemedicine consultation.

4) Risks and Benefits. The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.

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.

I acknowledge receipt of Blokes Authorization and Consent to Participate in Telemedicine/Telehealth Consultation

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