1. I understand that my Clinician wishes me to engage in a telemedicine consultation.
2. My Clinician has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/Clinician 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 Clinician 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 my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my Clinician and consulting Pinnacle Staff Member in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation.
6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting Clinician is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection. 911 could also be called by my Clinician in the event of a life threatening emergency.
7. I understand that billing will occur from Pinnacle Behavioral Health, IPA, LLC for copays or visit charges.
8. I have had a direct conversation with my Clinician, during which I had the opportunity to ask questions in regard to this process. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.