INFORMED CONSENT FOR TELEMEDICINE CONSULTATION:
The purpose of this form is to obtain your consent to participate in a telemedicine consultation with a licensed medical provider. Telemedicine involves using electronic communications to enable healthcare providers at different locations to share individual patient medical information to improve patient care. Details of your medical history, examinations, and diagnostic tests will be discussed using interactive video, audio, and/or telecommunications technology. The information may be used for diagnosis, therapy, follow-up, and/or education. All existing laws regarding access to medical information and copies of your medical records apply to this telemedicine consultation. I understand that my telemedicine consultation may include video, audio and/or digital photos and may be recorded. I understand that this telemedicine consultation is not a complete substitute for in-person visits with a medical provider and that certain medical conditions may require direct physical examination.
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 state law apply to information disclosed during this telemedicine consultation.
Patient Consent to the Use of Telemedicine:
I hereby give my informed consent for the use of telemedicine in my medical care. I hereby authorize my healthcare provider(s) at MyEMCDoc, LLC., to provide medical consultation via telemedicine in the course of my diagnosis and treatment.