TELEMEDICINE INFORMED CONSENT
By utilizing this telemedicine service, you acknowledge and agree to the following:
You are a current patient, or accepting to be a patient of Adler Familiy Practice and are 18 years or older. Your telemedicine appointment is not for an emergency situation. If you are having an emergency, please contact emergency services by calling 911 immediately.
By utilizing the Practice’s telemedicine services you agree:
Telemedicine involves the use of electronic communications. Electronic systems used will include measures to safeguard your information. Our providers may use the information you provide for purposes of diagnosis, recommending therapy or treatment follow-up and/or education.
The information you may be asked to provide may include any of the following:
Patient medical records
Live two-way audio and video
Output data from medical devices and sound and video files.
You will be responsible for any copayment, coinsurance, deductible or other out of pocket cost as determined by your insurance carrier and such may be charged by the practice before or after the telemedicine visit. If you are not covered by insurance, you will be responsible for the billed charges for the telemedicine service.
The potential benefits of this service may include, without guarantee, improved access to medical care by enabling a patient to remain in his/her location.
As with any medical procedure, there are potential risks associated with the use of telemedicine. While the likelihood may be low, these risks may include, without limitation, the following:
The inability to have direct, physical contact with the patient may impact the quality of service.
Certain limitations of telehealth services may require you to have an office visit.
Security protocols could fail, causing a breach of privacy of personal medical information.
Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes.
You hereby further acknowledge and agree to the following:
Telemedicine is one of the variety of modalities for the provision of medical care that may be available to me.
If my provider believes I would be better served by another form of service (e.g. in person), I may need to make an in-office appointment for appropriate care.
I have read and understand the information provided above regarding telemedicine and hereby authorize my provider and its employees, agents and independent contractors, to use telemedicine in the course of my diagnosis and treatment.
BY ACCEPTING THESE TERMS YOU HEREBY GIVE YOUR INFORMED CONSENT TO PARTICIPATE IN A TELEMEDICINE VISIT AND FOR THE USE OF TELEMEDICINE IN YOUR MEDICAL CARE.