1. I hereby authorize Burtonsville Family Health, LLC to use a Health Insurance Portability and Accountability Act (HIPAA) compliant practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.
2. I understand that technical difficulties may occur before or during the online sessions and my appointment cannot be started or ended as intended.
3. I accept that the professionals can conduct interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication 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 telemedicine practices and I may be responsible for any fee that my insurance company does not cover.
5. I agree that my medical records can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private according to HIPAA standards.