Consent to Telehealth Services
PURPOSE
The purpose of this form is to provide you with information about telehealth and to obtain your informed consent to participate in a telehealth health service from Connected Rheumatology, PLLC (the “Practice”) as part of your medical care.
NATURE OF TELEHEALTH
Telehealth involves the use of electronic communications to enable a healthcare provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telehealth allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. Your telehealth encounter may include interaction through and using the internet and real-time video, and may also include recorded audio communications, medical imaging, medical tests, and diagnoses, as well as related technologies known as “store-and-forward.”
BENEFITS
The benefits of telehealth include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. Telehealth also permits increased efficiency in evaluations, diagnoses, consultations, and treatment.
POTENTIAL RISKS
The potential risks associated with the use of telehealth are rare, but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to a patient’s failure to provide complete medical information or records.
INDEMNIFICATION
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PRACTICE, ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, AFFILIATES, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEHEALTH, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PRACTICE’S NEGLIGENCE.
ALTERNATIVES
Alternative methods of care may be available to you, such as in-person services. Your provider will explain any such options to you, and you may choose an alternative at any time without risking the loss or withdrawal of any health benefits to which you are entitled.
FOLLOW-UP CARE; EMERGENCY SITUATIONS
In some situations, telehealth is not an appropriate method of care. If there is an emergency situation, if you have an adverse reaction, if a technical failure prevents you from communicating with your telehealth provider, or if you believe telehealth will not provide sufficient safety and quality, you should seek care at an emergency room facility or other provider equipped to deliver emergent care. If the situation is an emergency, call 911. If the situation is not urgent or emergent, contact the Practice as indicated below so that you can discuss next steps with your provider.
PHONE: 972-310-0598
HOURS OF OPERATION: Monday – Thursday 9:00 am – 5:00 pm
YOUR PRIVACY RIGHTS
The Practice uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption; however, perfect data security is not possible. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in the Practice’s Notice of Privacy Practices.
If you have a concern about a medical professional, you may contact the Texas Medical Board regarding your concerns.
By signing this form, I understand the following:
- I understand how the telehealth technology will be used to conduct my healthcare visit, and have been given the opportunity to ask questions regarding the technology. I understand that this visit will not be the same as an in-person visit due to the fact that I will not be in the same physical location as the provider.
- I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telehealth provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telehealth is appropriate for me at this time, based on the condition being diagnosed and/or treated.
- I understand that, if I am prescribed any medication, I am free to obtain my prescription from any pharmacy of my choice.
- I understand that I may benefit from telehealth, but results cannot be guaranteed.
- I have been informed of the costs associated with my telehealth visit.
- I have the right to inspect and obtain copies of all information received and recorded during any telehealth session, subject to the policies of the healthcare providers involved in my care. I may be charged a fee for copies of my records in accordance with applicable rules. I have read and understand the information above and all of my questions have been answered to my satisfaction.
- I consent to the Practice’s providers, which may include, without limitation, physicians, physician assistants, and/or nurse practitioners providing services to me via telehealth.
FOR PURPOSES OF THIS INFORMED CONSENT, I UNDERSTAND AND AGREE THAT BY ACKNOWLEDGING THIS AGREEMENT I CONSENT TO BE EVALUATED AND TREATED VIA TELEHEALTH.
- I understand that I am free to obtain an evaluation and/or treatment elsewhere.
- I further understand that I will be responsible for any payments that apply to my telehealth visit. I agree that I will not submit the bills for these services to any commercial health insurance plan or governmental health insurance plan, including but not limited to Medicare, Medicaid, or Tricare.
- I have read, understand and agree to the Practice’s Notice of Privacy Practices.
The Practice may communicate with me, including about my personal medical information, using the following methods and the contact information I have associated with my User Account for the website operated by the Practice (check all you agree to):
- By sending me an email. info@connectedrheumatology.com.
- By leaving me a voicemail message.
- By texting me.
I agree to the above methods of unencrypted communication that I have selected, for my own convenience, and I accept all risks associated with them (including, without limitation, risks of improper exposure of my medical information).