1. I attest that I am preparing to engage in a telehealth consultation.
2. 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, but rather video conferencing technology will be used to affect the consultation.
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 payment for telehealth services is made in advance of the encounter, and is not refundable. I have been advised that my insurance will not be billed for this service.
5. I am aware that the outcome of my telehealth visit may require that I schedule an office visit with my provider to more effectively treat my condition. I recognize that subsequent office visits are not included in the cost of the telehealth visit, and will be billed separately.
6. I have had the opportunity to ask questions in regard to this procedure. 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.
By printing my name in the box below, I am signing the consent and 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 the risks 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.