Consent to Receive Telehealth Services
Consent to Receive Telehealth Services (children 12 years or older, adults 18 years of age and older and of sound mind)
Agreement to Telehealth:
I, the Patient, hereby agree:
1. To be serviced by the Practitioner from this Practice [if applicable: for a series of x nr of appointments],with whom I have an established practitioner-patient relationship, or: where I am a new patient and such telehealth will be in my best interest ], by means of electronic media (Skype, Zoom or similar; and/or by telephone and/or by Whatsapp Call or FaceTime call and/or applicable as authorized by the HPCSA.
2. I understand that this platform will be used to render healthcare services to me, and that the usual consent processes will be followed (i.e. I will be informed of my health status, as well as the benefits, risks and implications of the care). I understand that I can opt out of receiving care at any stage, but acknowledge that it may not be in my best interest and I therefore release the Practitioner from legal liable for such an opt-out.
3. There is no subscription required when using the electronic platforms mentioned above, such as costs for the Applications (“Apps”) used, but I understand that I will carry my own costs of any infrastructure and/or running costs associated with such service being rendered e.g. the data used, the telephone and/or computer, etc.
4. That the Practitioner may encourage me to present myself for a face-to-face consultation at a healthcare facility close to me, if he/she is in doubt that the telehealth consultation is in my best interest, provided that it would be safe for me, the Practitioner and others, to do so.
5. That I will be billed for a consultation at the rate of [insert] for [duration of interaction] or any part thereof. I also understand that, due to the nature of the current pandemic, that the Practitioner may have to give urgent attention to other patients, and/or have to move my appointment to a later or earlier time or day.
6. That my medical scheme may, or may not cover the costs of this care. I undertake to cover any shortfall that my scheme does not cover, which may be the full amount. However, I understand that the HPCSA allows such care during the time of the Covid Pandemic, and that certain services must be funded by my scheme in full.
7. To record-keeping of the session, i.e. the Practitioner’s notes, which are required by law [and, where applicable: ... and with my prior consent, to the recording of the live session as video and sound recording.]
8. That the service may have limitations relating to technology, such as data- and internet failures (e.g. dropped calls or bad reception).
9. That, although the Practitioner will adhere to the existing rules relating to confidentiality:
a. I understand that I must take the necessary precautions at home to ensure my confidentiality during telehealth service provision;
b. I understand that, should I want a family member, caregiver, parent or other person to attend the session with me (in person or through a remote internet connection), I will provide my written consent to such attendance prior to the consultation. I understand that without this, should such a person be in attendance, the engagement may be cancelled or rescheduled;
c. I understand that, and agree that, should the practitioner believe that I may have been exposed to Covid-19 and/or do have Covid-19, s/he would refer me for tests, and I understand that the results of such tests must be reported, by law, to the NICD – National Institute of Communicable Diseases.
I, therefore, freely and voluntarily consent to this service, and I understand the implications thereof, including the costs related to it.
Patient signature, which the Practice and Patient agree can be electronically affixed.