INFORMED CONSENT FOR TELEMEDICINE SERVICES INTRODUCTION

INTRODUCTION
Telemedicine involves the use of electronic communications to enable
health care providers at different locations to share individual
patient medical information for the purpose of improving patient care.
Providers may include primary care practitioners, specialists, and/or
subspecialists. The information may be used for diagnosis, therapy,
follow‐up and/or education, and may include any of the following:
-Patient medical records
-Medical images
-Live two‐way audio and video
-Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security
protocols to protect the confidentiality of patient identification and
imaging data and will include measures to safeguard the data and to
ensure its integrity against intentional or unintentional corruption.

EXPECTED BENEFITS
-Improved access to medical care by enabling a patient to remain in
his/her office (or at a remote site) while the physician obtains a test
results and consults from healthcare practitioners at distant/other
sites.
-More efficient medical evaluation and management.
-Obtaining expertise of a distant specialist.

POSSIBLE RISKS
As with any medical procedure, there are potential risks associated
with the use of telemedicine.
These risks include, but may not be limited to:
-In rare cases, information transmitted may not be sufficient (e.g.
poor resolution of images) to allow for appropriate medical decision
making by the physician and consultant(s);
-Delays in medical evaluation and treatment could occur due to
deficiencies or failures of the equipment;
-In very rare instances, security protocols could fail, causing a
breach of privacy of personal medical information;
-In rare cases, a lack of access to complete medical records may
result in adverse drug interactions or allergic reaction or other
judgment error

INFORMED CONSENT FOR TELEHEALTH AND TELEMEDICINE

BY PROCEEDING WITH ANY VIRTUAL CARE CALL WITH US, I ATTEST TO AND
UNDERSTAND AND CONSENT TO THE FOLLOWING:
1. I understand that the laws that protect the privacy and the
confidentiality of medical information also apply to telemedicine, and
that no information obtained in the use of telemedicine which
identifies me will be disclosed to researchers or other entities
without my consent,
2. I understand that I have the right to withhold or withdraw my
consent to the use of telemedicine in the course of my care at any
time, without affecting my right to future care or treatment,
3. I understand that I have the right to inspect all information
obtained and recorded in the course of a telemedicine interaction, and
may receive copies of this information for a reasonable fee,
4. I understand that a variety of alternative methods of medical care
may be available to me, and that I may choose one or more of these at
any time. Drs Hugo, Wolf and Dawson have explained the alternatives to
my satisfaction,

5. I understand that telemedicine may involve
electronic communication of my personal medical information to other
medical practitioners who may be located in other areas, including out
of state.
6. I understand that it is my duty to inform Drs Hugo, Wolf and Dawson
of electronic interactions regarding my care that I may have with
other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use
of telemedicine in my care, but that no results can be guaranteed or
assured.

PATIENT CONSENT TO THE USE OF TELEMEDICINE
I have read and understood the information provided above regarding
telemedicine, and all my potential questions have been answered to my
satisfaction. I hereby give my verbal informed consent for the use of
telemedicine in my medical care. I hereby authorize Drs Hugo, Wolf and
Dawson to use telemedicine in the course of my diagnosis and
treatment.