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 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; Please initial after reading this
page:
I ATTEST TO AND UNDERSTAND THE FOLLOWING:
1. I understand that the laws that protect 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
during 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 during
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. Telehealth NP has 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 in other areas, including out of state.
6. I understand that it is my duty to inform Telehealth NP 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.
CONSENT TO THE USE OF TELEMEDICINE
I have read and understand the information provided above regarding telemedicine, have discussed it with
my provider or such assistants as may be designated, and all my questions have been answered to my
satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I hereby voluntarily give my consent to evaluation and treatment at Telehealth NP through means of all
telehealth communications.
GENERAL PATIENT CONSENT FOR TREATMENT
I hereby voluntarily consent to all healthcare services ordered/provided by Telehealth NP providers at the
Telehealth NP service locations. The health care service may include, without limitation, routine physical
and mental assessment; diagnostic and monitoring tests and procedures; examinations and medical
treatment; routine laboratory procedures and test; x-rays and other imaging studies; administration of
medications; and procedures and treatments prescribed by the representative healthcare providers.
Consent Provisions
1. I certify that I have read and fully understand the foregoing consent and that the facts indicated above
are true.
2. I realize that although every effort will be made to keep all risks and side effects to a minimum, risks,
side effects, and complications can be unpredictable both in nature and severity.
3. I understand that Nurse Practitioners will be involved in treatment, and I consent thereto.
4. I understand Telehealth NP will make every effort to keep communications confidential and secure.
6. I hereby voluntarily give my consent to evaluation and treatment at Telehealth NP