CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION (The following information has been reviewed with the patient at the start of their telemedicine consultation visit by our healthcare team.
PURPOSE. The purpose of reviewing this information is to obtain a verbal consent by the patient for a telemedicine consultation with a healthcare provider.
PATIENT FINANCIAL RESPONSIBILITY: Telemedicine visit charges are billed and collected in the same manner as regular in office treatments. As a courtesy to our patients, we will submit all claims to your primary and secondary insurance carriers in a timely manner. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered by your plan. Patients are responsible for knowing the details/rules of their health plan(s), as we cannot change our coding to obtain payment. Telemedicine visits are subject to copays, coinsurance and deductibles. If your insurance denies the claim as “not covered” you will be held personally responsible for your bill.
NATURE OF TELEMEDICINE CONSULTATION. Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken.
RISKS, BENEFITS AND ALTERNATIVES. The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a healthcare provider.
MEDICAL INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.
CONFIDENTIALITY. All existing confidentiality protections under federal and New York State law apply to information used or disclosed during your telemedicine consultation.
RIGHTS. You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Waiver/Release. You understand and agree that you solely assume the risk of any errors or deficiencies in the electronic transmission of information during your telehealth visit or in the electronic submission of your images to your dermatologist and further understand that no warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis. To the extent permitted by law, you also agree to waive and release your dermatologist, physician assistant and nurse practitioner and Javier Zelaya MD PC from any claims you may have about this advice or the telehealth visit generally.
REVIEW. Skinworks Dermatology has discussed with me the information provided above. I understand that I have been provided this form for my records and that I have verbally agreed to a telemedicine consultation visit. I understand that I have had an opportunity to ask questions about this information and all of my questions have been answered.