Telemedicine Appointment Educational Material and Consent Form

Telemedicine is a way to meet with healthcare providers using a phone, tablet, or computer.

Telemedicine lets a doctor or other provider care for you, even when you cannot visit him or her in person. The doctor or other provider uses the Internet or other technology to: give you advice, give you an exam, do a simple procedure, refill prescriptions, or talk with other providers about your health or a treatment. Telemedicine is more than an email, a fax, or an online questionnaire. Sometimes you may need to come to a healthcare facility to use equipment (TV screen, camera, or Internet A provider may need to use technology tools or medical devices to check on your health remotely. If you agree, part of your health record may be sent to the telemedicine provider before your appointment.

You and your healthcare team must decide if your health problem can be helped with telemedicine. The team and others involved in your care (e.g., medical home or hospital teams) will make a plan for your care using telemedicine. This will also include steps for handling an emergency during the telemedicine appointment.

If the patient is a minor child, the telemedicine provider will explain to the parent how a telemedicine exam is different from an in-person exam. He or she will also explain if a complete exam of the child is possible.

During your telemedicine session:

The provider and the staff will introduce themselves. You may be asked to confirm the state you are in and the state where you live. The provider may talk to you about your health history, exams, x-rays, and other tests. Other providers may take part in this discussion. A visual and/or partial physical exam may take place. This may happen by video, audio, and/or or with other technology tools. A nurse or other healthcare staff may be in the room with you to help with the exam. Non-medical staff may be in the room to help with the technology. Video and/or photo records may be taken, and audio recordings may be made. This should only be done by the provider. Patients should not take any video and/or photo or audio recordings of the visit. A report of the session will be placed in your medical record. You can get a copy from your provider.

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All laws about the privacy of your health information and medical records apply to telemedicine. These laws also apply to the video, photo, and audio files that are made and stored.

Many patients like telemedicine because they do not have to spend time and money on travel to see a certain healthcare provider in person. Also, they can see a provider who they might not be able to see otherwise.

Technology can make getting health care easy, but there can also be problems:

If there is an equipment or Internet problem, your diagnosis or treatment could be delayed. Records or images that are taken and sent may be poor quality. This can delay or cause problems with your diagnosis or treatment. The records sent for review before the session may not be complete. If this happens, then it may be hard for the telemedicine provider to use his or her best judgment about your health problem. For instance, you could have an allergic response to a drug if the provider does not have all the facts about your health. There could be problems with Internet security and privacy. For instance, hackers may be able to view your health information. If this happens, then your medical records may not stay private. Other people around you may hear your private health information. It is important that you have a secure space for your appointment. It should only include people who you are willing to share health information with. This is your responsibility, and you should end the visit if you believe the information is not private. If there is a technology problem, the information from your session may be lost. This would be outside the control of telemedicine provider. Without a hands-on exam, it may be hard to diagnosis your problem.

A main goal of telemedicine is to make sure that you get good, personal health care, even though you are not seeing a provider in person. Sometimes your provider may decide that to treat your health condition, you may need an in-person visit. Some states may require you to have a face-to-face visit first and a yearly visit with your doctor before telemedicine treatment can happen. Telemedicine providers must follow the same rules for prescribing drugs just as they would for an office visit. Before your session, you will learn about which drugs telemedicine providers can and cannot prescribe. This may also include talking about controlled substances.

Having a telemedicine appointment is your choice. Even if you have agreed, you can stop your medical records from being sent - if this has not happened yet. You can stop the session at any time. You can limit the physical exam.

You will be told about all staff who will take part in the appointment. You can ask that any of these

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people leave the room to stop them from seeing or hearing the information being shared. Your appointment may end before all problems are known or treated. It is up to you to get more care if your health problem does not go away. You will be told how long it might take to respond to your emails, phone calls, or other types of

The cost of a telemedicine visit will depend on your type of insurance policy. Before your appointment, you may want to ask how much will be covered by your insurance policy.

This form gives you facts about and risks of telemedicine. By signing this form, you are confirming that you have read, understand, and agree with these terms. I also confirm by my signature below that:

I have been told the name and credentials of my telemedicine provider. I have a right to stop using telemedicine at any time, even during my visit. If I choose to stop my visit, I can call the office to schedule an appointment for an in-person visit. I understand that using electronic communications poses a risk for exposing my health information. I have been able to ask questions about telemedicine. All my questions have been answered. I understand no guarantees have been made about success or outcome. I agree to take part in a telemedicine appointment.

Copyright © 2022. Curi. All rights reserved.