Alternative options: No Treatment or Office Consultation when available.
During the telemedicine/Teledentistry consult:
Details of your medical history, examinations, x-rays and tests will be discussed with other
health professionals through the use of interactive video, audio and telecommunication
A physical examination of you may take place through use of video technology when
Video, audio and/or photo recordings may be taken of you during the procedure(s) or
2.MEDICAL INFORMATION & RECORDS: All existing laws regarding your acess to medical/dental information and copies of your medical/dental records apply to this telemedicine consult. Please note not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or infomration for this telemedicine interaction to researchers or other enties shall not occur without your consent.
3.CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and New York state law apply to information disclosed during this telemedicine consultation.
4.RIGHTS: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment.
5.DISPUTES: You agree that any dispute arriving from the telemedicine consult will be resolved in New York and that New York law shall apply to all disputes.
6.I have been informed of and understand that follow up visits or care, additional evaluation, treatment or surgery, and/or hospitalization may be needed.
7.RISK AND CONSEQUENCES: You have been advised of all the potential risks, consequences and benefits of telemedicine. Your health care practitioner has discussed with you the information provided above. You had the opportunity to ask questions about the information present on this form and the telemedicine consultation. All your questions have been answered, and your understand the wriden information provided above.