PATIENT CONSENT TO TELEMEDICINE SERVICES
PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR OWN RECORDS.
In order to reduce possible exposure to COVID-19 (Coronavirus), Beauty & Body Hillcrest/Solana Beach is implementing: (1) telemedicine virtual visits via audio-visual, real-time, two-way interactive communication system for new and established patients; (2) virtual check-ins by telephone and/or audio-visual, real-time, two-way interactive communication for established patients; and (3) E-visits via online patient portals for established patients.
I, the undersigned, do hereby request and consent to an evaluation and treatment via telemedicine technologies.
I understand that telemedicine is being utilized during the COVID-19 pandemic as a way to reduce potential exposure to the virus and that face-to-face encounters in accordance with applicable law will resume once the risks associated with the virus have been minimized.
I understand that although Beauty & Body Hillcrest/Solana Beach has taken reasonable steps to protect my privacy, because this is in response to a national health emergency, telemedicine services may not comply with all of the HIPAA privacy and security requirements. Specifically, Beauty & Body Hillcrest/Solana Beach will deliver telemedicine health care services using the following platforms: Doxy.me
I understand that I have the right to withdraw consent at any time before or after the consult without affecting my right to future care or services from Beauty & Body Hillcrest/Solana Beach
I understand that there are risks and consequences associated with receiving clinical health care services via telemedicine communication that are beyond Beauty & Body Hillcrest/Solana Beach’s control, including but not limited to, disruption of transmission by technology failures, poor image quality, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
I understand that in lieu of this telemedicine encounter, I may seek health care services elsewhere where I might have face-to-fact contact with a health care provider.
I understand there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
I understand that the privacy laws of confidentiality of my protected health information (“PHI”) also apply to telemedicine health care services unless an exception to confidentiality applies or is required by law.
I wish to rely on Beauty & Body Hillcrest/Solana Beach to exercise judgment for my best interest during my course of treatment during the COVID-19 national health emergency. I will inform Beauty & Body Hillcrest/Solana Beach of any sensitive areas or adverse conditions that I may have had prior to, during, or after treatment. I intend this consent to cover my entire course of treatment during the COVID-19 national health emergency.
I understand that any questions I may have regarding the potential side-effects, complications, treatment or treatment area may be directed to Beauty & Body Hillcrest/Solana Beach during my evaluation and course of treatment during the COVID-19 national health emergency.