1. PURPOSE: The purpose of this form is to obtain your consent to participate in telemedicine consultations in connection with the following procedure(s) and/or services:
2. DEFINITION OF TELEMEDICINE: The remote delivering of health care services via technology-assisted media. This includes a wide array of clinical services and various forms of technology. The technology includes, but it not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system, or other electronic means. The delivery method must be secured by two-way encryption to be considered secure. Synchronous (at the same time) secure video chatting is the preferred method of service delivery.
3. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:
Details of your medical history, examination, x
rays, digital imaging, and tests will
be discussed with the patient and/or other health professionals through the use
video, audio, and telecommunication technology.
A physical examination of the patient may take place.
Video, audio, and/or photo recordings may be taken of the patient during the
telemedicine session as part of patient charting and records.
PATIENT RIGHTS: I understand that telemedicine also involves the communication of my medical/mental health information, both orally and visually, to my provider who may be within Idaho or outside of Idaho at the time of communication. I understand that I have the following rights with respect to telemedicine:
I have the right to withhold or withdraw consent at any time without affecting my right
to future care or treatment, nor risking the loss or withdrawal of any program benefit to
which I would otherwise be
The laws that protect the confidentiality of my medical and mental health information
also apply to telemedicine. As such, I understand that the information disclosed by me
during the course of my telemedicine appointment is confidential. Ho
wever, there are
both mandatory and permissive exceptions to confidentiality, including, but not limited
to reporting child, elder, and dependent adult abuse; expressed threats of violence
toward self and/or an ascertainable victim; and where I make my men
tal and emotional
state an issue in a legal proceeding.
I understand that there are risks and consequences from telemedicine, including, but not limited to the possibility despite reasonable efforts on the part of my provider, that the transmissions of my medical and mental health information could be disrupted or distorted by technical failures; the transmission of my medical or mental health information could be interrupted by unauthorized persons; and/or limited ability to respond to emergencies. The offices of Bonner General Health decrease the likelihood of interruptions. However, there are ways to minimize interruptions and maximize privacy and effectiveness. Your provider will take every precaution to insure technologically secure and environmentally private sessions. As the patient, you are responsible for finding a private, quiet location where the sessions may be conducted. If it is determined that I would be better served by another form of service (e.g. face to face services), my provider will attempt to accommodate these services. Finally, I understand that there are potential risks and benefits associated with any form of medicine, and that despite my efforts and the efforts of my provider, my condition may not improve.