(1) PURPOSE: The purpose of this form is to obtain your consent to participate in telehealth consultation.
(2) NATURE OF TELEHEALTH CONSULT: During the telehealth consultation: a. Details of your medical history, examinations, x-rays, and test will be discussed. b. A physical examination of you may take place.
(3) MEDICAL INFORMATION AND RECORDS: All existing laws regarding your access to medical information and copies of your medical record apply to this telehealth consultation. Please note, telecommunications are not recorded or stored. Additionally, dissemination of any patient-identifiable images or information for this telehealth interaction shall not occur without your consent.
(4) CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telehealth consultation, and all existing confidentiality protections under federal and Texas state law apply to information disclosed during this telehealth consultation.
(5) RIGHTS: You may withhold or withdraw consent to the telehealth consultation at any time without affecting your right to future care or treatment.
(6) RISKS, CONSEQUENCES AND BENEFITS: You have had the opportunity to ask questions about the information presented on this form and the telehealth consultation. All your questions have been answered, and you understand the written information provided above.