TELEHEALTH INFORMED CONSENT PDF

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Name* This field is required.
First Name
Last Name
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Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
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I understand that telehealth involves the communication of my medicalmental healthinformation in an electronic or technology-assisted format.I understand that I may opt out of the telehealthvisit at any time. This will not change myability to receive future care at this office. I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Florida at the time of this service. USE YOUR FINGER ON THE SCREEN OR MOUSE TO INITIAL* This field is required.
Write Initials with finger or mouse
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I understand that telehealth involves the communication of my medicalmental healthinformation in an electronic or technology-assisted format. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that I may opt out of the telehealthvisit at any time. This will not change myability to receive future care at this office. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Florida at the time of this service. INITIAL WITH FINGER OR MOUSE * This field is required.
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I understand that telehealth billing information is collected in the same manner as aregular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibilityto check with my insurance plan to determine coverage.INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that all electronic medical communications carry some level of risk. Whilethe likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures. USE YOUR FINGER ON THE SCREEN OR MOUSE TO INITIAL* This field is required.
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I agree that information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care. INITIAL WITH FINGER OR MOUSE* This field is required.
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.I understand that medical information, including medical records, are governed byfederal and state laws that apply to telehealth. This includes my right to access myown medical records (and copies of medical records. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that Skype, FaceTime, or a similar service may not providea secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed. INITIAL WITH FINGER OR MOUSE* This field is required.
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I agree that information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care. of medical information could be disrupted or distorted by technical failures.the doctors, other healthcare providers, and healthcare facilities involved in my care.I understand that medical information, including medical records, are governed byfederal and state laws that apply to telehealth. This includes my right to access myown medical records (and copies of medical recordsI understand that Skype, FaceTime, or a similar service may not providea secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed. USE YOUR FINGER ON THE SCREEN OR MOUSE TO INITIAL* This field is required.
Write Initials with finger or mouse
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I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others. INITIAL WITH FINGER OR MOUSE* This field is required.
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The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me. INITIAL WITH FINGER OR MOUSE* This field is required.
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I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that I must take reasonable steps to protect myself from unauthorized useof my electronic communications by others.The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.I agree that I have verified to my healthcare provider my identity and current locationin connection with the telehealth services. I acknowledge that failure to comply withthese procedures may terminate the telehealth visit. USE YOUR FINGER ON THE SCREEN OR MOUSE TO INITIAL* This field is required.
Write Initials with finger or mouse
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I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that electronic communication cannot be used for emergencies or time-sensitive matters. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that electronic communication cannot be used for emergencies or time-sensitive matters. I understand and agree that a medical evaluation via telehealth may limit my healthcareprovider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—includingfurther diagnostic testing, such as lab testing, a biopsy, or an in-office visit. USE YOUR FINGER ON THE SCREEN OR MOUSE TO INITIAL* This field is required.
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I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications. INITIAL WITH FINGER OR MOUSE* This field is required.
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By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided. INITIAL WITH FINGER OR MOUSE* This field is required.
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To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit. INITIAL WITH FINGER OR MOUSE* This field is required.
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I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community. INITIAL WITH FINGER OR MOUSE* This field is required.
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By signing below I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit. I understand that there is never a warranty or guarantee as to a particular result oroutcome related to a condition or diagnosis when medical care is provided. To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit. I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community. USE YOUR FINGER ON THE SCREEN OR MOUSE TO INITIAL* This field is required.
Write Initials with finger or mouse
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I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the opportunity to have questions answered to my satisfaction.For electronic communication between Dr. Audrey Farahmand and staff and TYPE FIRST AND LAST NAME* This field is required.
Type Patient's First and Last Name with keypad
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Type Patient or Legal Representative Name* This field is required.
First Name
Last Name
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Patient or Legal Representative Signature - Sign with finger or mouse* This field is required.
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Relationship to Patient* This field is required.
Type with keypad
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Healthcare Provider Signature/Date/Time
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I understand that due to the state of the current national emergency crisis, telehealth is offered by Dr. Audrey Farahmand to appropriate patients in an effort to comply with federal and state mandates of isolation and social distancing as an effort to provide protection to everyone.

The purpose of this form is to obtain your consent for a telehealth visit with one of our health care providers at the office of Farahmand Plastic Surgery. The purpose of this visit is for the care of Cosmetic/Plastic Surgery during the national emergency.
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