Consent & Terms

To better serve the needs of people in the community, health care services are now available by interactive video communications and/or by the electronic transmission of information. This may assist in the evaluation, diagnosis, management and treatment of a number of health care problems. This process is referred to as “telemedicine” or “telehealth.” This means that you may be evaluated and treated by a health care provider or specialist from a distant location. Since this may be different than the type of consultation with which you are familiar, it is important that you understand and agree to the following statements.

1. The consulting health care provider or specialist will be at a different location from me. A physician or other health care provider (“presenting practitioner”) may be present with me in the room to assist in the consultation.

2. The presenting practitioner may transmit or share electronically details of my medical history, examinations, x-rays, tests, photographs or other images with the specialist who is at a different location.

3. I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, the presenting practitioner and, via video, the consultant. I will give my verbal permission prior to the entry of the additional personnel.

4. The physician or health care provider for whom the on-site examination or treatment is performed (that is, the “presenting practitioner”) will keep a record of the consultation in my medical record.

5. RELEASE OF INFORMATION: Physicians who provide professional services to the patient are authorized to furnish medical information from my emergency medical record to the referring physician, if any, and to any insurance company or third party payer for the purpose of obtaining payment of the account. The physician is authorized to release information from my medical record to any other health care facility or provider to which my care may be transferred.

6. I voluntarily consent to health care services provided by my doctor(s) or a designee, which may include diagnostic tests, drugs, examinations, and medical or surgical treatments considered necessary to treat my health problem.

7. I understand that I may be released before all my medical problems are known or treated and it is my responsibility to make arrangements for follow-up care.

8. I understand that I have the option to refuse telehealth service at any time without affecting the right to future care or treatment and without risk of losing benefits.