TELEMEDICINE PATIENT CONSENT
PURPOSE: The purpose of this form is to obtain your consent to participate in a telemedicine appointment in connection with your follow up care with Psych Atlanta.
NATURE OF TELEMEDICINE CONSULT: During the telemedicine appointment details of your medical history, exams, and tests will be discussed using interactive video, audio, and telecommunication technology.
MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine appointment. Please note that telecommunications are not recorded or stored.
CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentially risks associated with the telemedicine appointment, and all existing confidentiality protections under Federal and Georgia state law apply to information disclosed during this telemedicine appointment.
RIGHTS: You may withhold or withdraw consent to the telemedicine appointment at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
DISPUTES: You agree that any dispute arriving from the telemedicine appointment will be resolved in Georgia, and that Georgia law shall apply to all disputes.
FINANCIAL RESPONSIBILITY: All the financial agreements and consents you have signed will apply to telemedicine appointments. You will be responsible for all copays, deductibles, co-insurance, or self-pay charges as you would if you were seen in our office. Our standard missed appointment fees will apply. You also agree that you will complete a credit card authorization form that will allow us to keep an active credit card on file that will be used for telemedicine appointments. Your card will be charged prior to your appointment.
RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences and benefits and telemedicine. You have had the opportunity to ask questions about the information presented on this form and the telemedicine appointment. All your questions have been answered, and you understand the written information provided.