Consent to Participate in TeleHealth

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

1. PURPOSE. The purpose of this form is to obtain your consent for a telehealth visit with one of our healthcare providers. I understand that due to the state of the current national emergency crisis, telehealth is offered by Ventura County Radiation Oncology Centers Medical Group, Inc. to appropriate patients in an effort to comply with federal and state mandates of isolation and social distancing as an effort to provide protection to everyone.

2. NATURE OF TELEHEALTH. Telehealth 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 telehealth visit, 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.

3. RISKS, BENEFITS AND ALTERNATIVES. The benefits of telehealth 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 telehealth is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth 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 physician.

4. 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 telehealth consultation to researchers or other entities shall not occur without your consent.

5. CONFIDENTIALITY. All existing confidentiality protections under federal and California law apply to information used or disclosed during your telehealth visit. I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.

6. RIGHTS. You may withhold or withdraw your consent to a telehealth visit at any time before and/or during the visit without affecting your right to future care or treatment

By signing this form,

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.

I understand that I can be charged the additional fees that my insurance does not cover.

I accept that I authorize health care professionals and use telemedicine for my treatment and diagnosis.