TELEMEDICINE PATIENT CONSENT
PURPOSE: The purpose of "Telemedicine Consent Form" is to get the patient's consent in order to participate in appointments of telemedicine cares. This is for care of minor, non-emergency conditions in a stable person. In case of emergency, you must stop and dial 9-1-1 immediately.
LOCATION: You must be in your HOME or place with similar levels of privacy during the visit. You must not be in a VEHICLE or other public place.
NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:
Details of your medical history, examinations, x-rays, and test will be discussed with you and/or other health professionals through the use of interactive video, audio, and telecommunication technology.
A physical examination of you may take place within the limits of available technology
A person skilled in telemedicine technology/internet technologies may be present during the visit to aid in the video transmission or to troubleshoot other problems that may arise during the visit
If required, video, audio and/or photo recordings may be taken of you during the service in order to aid in management planning, but not as a part of your medical record.
RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.
CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telemedicine consultation.
RIGHTS: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
DISPUTES: You agree that any dispute arriving from the telemedicine consult will be resolved in Georgia, and that Georgia law shall apply to all disputes.
RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences and benefits of telemedicine. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered, and you understand the written information provided above. I agree to participate in a telemedicine consultation for the procedure(s) described above.
ACCESS: The patient accepts that he/she needs access to PC, laptop, or mobile device and a good internet connection in order to have an efficient telemedicine appointment. The best is broadband internet.