Telehealth Consent
By signing this form, I understand and agree that Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. In addition to myself, members of my health care team, my family members, or my other legal representatives/guardians may join and participate on the telehealth/telemedicine services, and I agree to share my personal health information with such family members, caregivers, legal representatives or guardians. The information may be used for diagnosis, therapy, follow-up and/or education.
1. I hereby authorize Hillside Primary Care, PLLC, dba; Hillside Medical Group and all of its other dba’s to use the telehealth practice platform for telecommunication to provide the evaluation, testing and diagnosing of my medical condition(s).
2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment may not be started or ended as intended. Disruption of signals or problems with the internet may cause broadcast or reception problems that may prevent effective interaction between the consulting clinician, patient and the healthcare team. As with any internet based communication, I understand that there is a risk for security breaches.
3. I accept that the professionals can conduct interactive sessions with video call; however, I am informed that the sessions can also be conducted via regular voice communication (i.e. phone) if the technical requirements such as internet speed cannot be met.
4. I understand that my current insurance may not cover the additional fees of the telehealth practices and that I will be responsible for any fee that my insurance company does not cover.
5. I agree that my medical records from telehealth services can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
6. I understand that I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinic services. I have read, understand and agree to above with the requirements.