1086 Teaneck Road, Suite 4C Teaneck, NJ 07666
This consent is for all telehealth services provided to me by the physicians at Teaneck Gastroenterology Associates, (Dr. Michael Schmidt, Dr. Philip Micale, Dr. Adam Palance, Dr. Judy Lin and Dr. Sara Welinsky
TELEHEALTH is the use of the internet to provide remote health care for patients. Such care may come from doctors, nurses, mental health providers and professional health educators.
Specifically, a health care professional will be communicating with me remotely via the internet using doxy.me, a web-based audio-video software (referred to in this form as Telehealth Appointment Doxy.me only hosts the software and does not provide medical advice or information.
TheTelehealth Appointment may be for diagnosis, continuity of care, treatment, testing or medical consultation deemed necessary by my healthcare provider for me.
I UNDERSTAND that during a Telehealth Appointment:
Details of my medical history and personal health information may be discussed with me and or other health professionals. Audio, video or photo recordings containing medical details may be transmitted via secure channels and those details may become part of my permanent medical record. All confidential protections granted to me by various state and federal laws also apply to my care during this appointment. Industry-standard network and software security protocols are in place that protect the privacy of the communication and safeguard my transmitted information against eavesdropping and corruption. There may be security and privacy risks associated with Internet-based communications. Either my Healthcare Provider or I can discontinue the Telehealth appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic decision-making or for providing the care I desire. In addition to my healthcare provider (named above), I will be informed of any other persons who may be present during the appointment and have the right to have them leave the viewing and listening area. To maintain my privacy, I need to ensure that my viewing and listening area is limited to myself and any other person that has a need to participate during the virtual appointment. Dueto the limitations of telehealth that are out of my control (such as an unreliable internet connection) I will call local authorities (9-1-1) to assist me with a medical emergency. I have the right to omit or withhold specific details of my medical history/physical examination that are personally sensitive. My Healthcare Provider may advise me to seek immediate treatment or determine that there is a medical emergency and, as such, local authorities may be given my personal details to assist me. The communication is privileged and confidential, and I will not record the audio or video without first seeking the permission of my Healthcare Provider.
THEREFORE, BY CONSENTING TYO THIS TELEHEALTH APPOINTMENT: