1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
2. I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; This location will uphold the privacy as that of a regular office visit. I understand that this consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit.
5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
6. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
7. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse.
8. The Services will not be used for medical emergencies or other time-sensitive matters. If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.
9. Once seen in consultation, a record of the visit will be permanently made in your medical file via the EMR used in Healthway Medical Clinic and hence can be seen by other Physicians involved in your medical care.
10. . Video transmission will consist of the Patient and the consulting Physician. This video will not be recorded.
11. The consulting Physician will NOT be prescribing Stimulants, Narcotics or Benzodiazepines over Telemedicine.
12. I understand that the consulting Physician will be able to access Pharmanet, if needed, to review medications that I am taking. This is needed when a prescription refill is the reason for the visit or when otherwise deemed appropriate by the physician.
13. Telemedicine visits are to be used for medical issues that do not require a physical examination. Lab work review, referrals to specialists and certain medication refills are part of services that are offered via Telemedicine. It is important to note that the consulting Physician will deem what can and cannot be conducted for the visit.