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Telemedicine services involve the use of secure interactive videoconferencing
equipment and devices that enable health care providers to deliver health care
services to patients when located at different sites.

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
   1. If it is determined that the videoconferencing equipment and/or  connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
   1. I may revoke my right at any time by contacting Dr. Kasper's Medical Group at 832-948-6942.
5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
7. I understand that this document will become a part of my medical record.
   By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).

You have been given the Notice of Privacy Practices for Dr. Kasper's Concierge Medical Group.  This Notice describes your legal right regarding your health information and will inform you of the legal duties and privacy policies.  If you receive services by your physician or other health care provides at a different location, you may want to ask about the office or clinic's health information privacy policies and notices.  they could be different.  

This Notice of Privacy Practices is one document for your convenience.  This practice is independently responsible for complying with this Notice.  We are not responsible for each other's action and do not have equal control over the other's business.

Your legal name and signature below indicate that you have read and understand this Notice of Privacy Practices. Click HERE to download a copy of our Privacy Practices.  

If you have a question regarding any of the information set forth in this Notice of Privacy Practices, please do not hesitate to contact Dr. Kasper's Concierge Medical Group office at (832) 948-6942. 

 

My signature indicates that I have read and acknowledge the above Consent to Treatment, Release of Information and Notice of Privacy Practices and agree to all the terms as indicated.

*If signed by a Qualified Personal Representative, the following must be completed:

Dr. Kasper's Concierge Medical Group occasionally sends newsletters, updates and event information to the provided email address or phone number.  I understand that I may opt out of receiving these communications at any time and I consent to the use of my email address and phone number for these purposes.  Some tests results may be sent to you via ENCRYPTED EMAIL.  A consent is required to have results sent by this method.

In an effort to improve the continuity of care, you may be referred to a primary care physician, if you do not already have one and/or a specialist.  The referral information will be provided to you as a part of your discharge paperwork.  Do you consent to Dr. Kasper's Concierge Medical Group providing the Referral Physician your contact information for the purpose of contacting you to setup a follow up visit?

If you select YES, Your name, phone number and reason for referral will be provided.

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations

333 Guadalupe, Tower 3, Suite 610

P.O. Box 2018, MC-263 Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number:

1-800-201-9353

For more information, please visit our website at

www.tmb.state.tx.us.

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