Telemedicine involves the use of electronic communications to allow healthcare providers at League City Family Clinic to provide services to individuals located at a different site than the provider. These services can be used for diagnosis, therapy, follow-up and/or education. Telemedicine consultations are available to new and established League City Family Clinic patients.
PURPOSE: The purpose of this form is to obtain consent to participate in a telemedicine consultation in connection with the following procedure(s) and/or service(s).
NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:
Details of your medical history, examinations, x-rays and labs will be discussed with other health professions through the use of interactive video, audio, and telecommunication technology.
a) A non-medical technician may be present in the telemedicine studio to aid in the video transmission.
b) Video,audio and/or photo recordings may be taken of you during the service(s)
PAYMENT OF SERVICES: You agree that League City Family Clinic reserves the right to bill a telemedicine visit to your respective insurance company. As well, you are responsible for any patient portion of the telemedicine consult.
SCHEDULE YOUR TELEMEDICINE APPOINTMENT:
Please set up patient portal before telemedicine consultation.
Payment is due at time of scheduling
An email will be sent with a link for access to your telemedicine appointment
If using Healow App, the facility code will be AEGGBD
SIMPLE STEPS TO LOG INTO YOUR TELEMEDICINE VISIT:
You can use phone, tablet, laptop or desktop
You must have a connection to the internet
Phones will work, only if connected to Wi-Fi
You must use Google Chrome, have a microphone and camera
Go to your email and access the link provided for televisit
Improved access to medical care by enabling a patient to remain in his/her current setting
More efficient medical evaluation and management.
There are potential risks associated with the use of telemedicine, which include, but are not be limited to:
The provider may determine that the information is insufficient, thereby requiring the patient to see the provider in a face to face environment or to seek emergency medical treatment.
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
By signing this informed consent you acknowledge that you understand and agree with the following:
I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to other entities without my written consent.
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.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
I understand that I am responsible for any co-payments, deductibles, coinsurances or other payments that apply to my telemedicine visit.
I have read this document fully, and understand the risks and benefits of telemedicine and have had my questions regarding the consultation explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.