CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION

1. PURPOSE:The purpose of this form is to obtain your consent for a telemedicine  consultation with a health care provider.
2. NATURE OF TELEMEDICINE CONSULTATION :  Telemedicine involves the use of audio, video or other eletronic communications to intract 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 intractive 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. Thebenefits of telemedicine include having access to health care providers 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 after the telemedicine appoitment privacy. The alternative to telemedicine consultation is a face-to face visit with a health care provider.
4. MEDICAL INFORMATION AND RECORDS. All Laws concerning patient access to medical records and copies of medical records apply to telemedicine. Disssemination f any patient identifiable images or information from the telemedicine consultation ot researchers or other entities shall nt=ot occur without your consent.
5. CONFIDENTIALITY. All existing confidentiality protections under federal and California law apply to Information used or disclosed during your telemedicine consultation.
6. RIGHT. You may with hold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to futured care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

My healthcare provider has discussed with me the information provided above. I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsility.If your insurance does not cover telemedicine, payment is due prior to telemedicine services.I have had an opportunity to ask questions about this information and all of my questions have been answered.I have read and agree to a telemedicine consultation.