I verify that the above is my correct legal name. I give consent to Telemedora, PC to give me medical treatment.

I allow Telemedora, PC to file for insurance benefits to pay for the care I receive.

I understand that:

· Telemedora, PC will have to send my medical record information to my insurance company.
· I must pay my share of the costs.
· I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
· I have the right to refuse any procedure or treatment.
· I have the right to discuss the risks and benefits of all procedures and treatment proposed by my health care provider(s), together with any available alternatives.
· Telemedora, PC will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
· Before prescribing any controlled substance to me, Telemedora, PC may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.
· I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Telemedora’s standard policies regarding request and receipt of medical records and applicable law.
· The laws of the state in which I am located will apply to my receipt of telehealth services.

TELEHEALTH CONSENT

1.     I hereby authorize Telemedora, PC to use a telehealth platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2.     I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3.     I understand and agree 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 telehealth practices and I may be responsible for any fee that my insurance company does not cover.

5.     I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

6.     I understand and agree that:

·       I will not be in the same location or room as my physician.

·       My Telemedora, PC physician is licensed in the state in which I am receiving services. I will report my location accurately during registration.

·       Potential benefits of telehealth (which are not guaranteed or assured) include: (i) More efficient medical evaluation and management. (ii) Allows you to access medical care from the comfort of your home, reducing the need for travel and minimizing disruptions to your daily routine. (iii) Improved access to specialists, even if they are located far from your area, ensuring timely and expert care regardless of location. (iv) Enables continuity of care for chronic conditions. (v) Minimizes your risk of exposure to contagious illnesses, particularly in times of widespread infections, by avoiding in-person visits to clinics.

·       Potential risks of telehealth include: (i) Limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my physician in diagnosis and treatment; (ii) My physician’s inability to conduct a hands-on physical examination of me and my condition; and (iii) Delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Telemedora, PC, its physicians or employees, responsible for lost information due to technological failures.

·       I further understand that my Telemedora, PC physician’s advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my Telemedora, PC physician relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

·       I may discuss the risk, benefits of medical treatment and its alternatives with my Telemedora, PC physician and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by Telemedora, PC.

·       I understand that the level of care provided by my Telemedora, PC physician is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.

·       I have the right to receive face-to-face medical services at any time by traveling to a medical center that is convenient to me.

·       In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.

Notice:

Before we proceed with your appointment, this is to inform you about an important aspect of how we document our encounter.  Your doctor may utilize an Artificial Intelligence Note taking scribe called AI Scribe.

All notes taken by AI Scribe will ALWAYS be reviewed by your doctor for accuracy before being made of your medical records.

Please note that the AI Scribe does not replace your doctor’s clinical judgement. All medical decisions are made by your doctor.

Why do we use AI Scribe?

To accurately and efficiently capture the details of your discussion with your doctor.

To allow your doctor to focus more on you rather than typing note.  

Your data privacy is important for us. Therefore, we only use AI Scribe with HIPAA compliance data privacy and safeguards in place.

Your right:

You have the right to opt-out of the use for AI Scribe before or during your encounter. This will not impact your care.  

Your consent:

In order to use this technology, we need your consent. Please understand that your information will be handled with the utmost care, and the use of AI Scribe is aimed solely at improving your healthcare experience.

By signing this consent form, you acknowledge that:

1. You have been informed about the use of AI Scribe and its purpose.

2. You understand how your information will be handled, stored, and protected.

3. You agree to allow your clinician to use AI Scribe to assist with documenting your encounters.

4. You understand that you can withdraw your consent at any time without affecting the quality of care you receive.