Telemedicine Consent

What is Telemedicine?

Telemedicine (also sometimes called telehealth or telehealth visits or televisits) services are a way to deliver healthcare services locally to a patient when the healthcare provider is located at a distant site. Telemedicine is generally defined as the use of electronic information and communications technology to exchange medical information from one site to another site to provide medical or surgical treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion or medical advice to, a patient. Telemedicine can be used for diagnosing, treating, and prescribing medication.

When a healthcare provider believes a patient may benefit from the use of telemedicine services, telemedicine can maintain a continuity of care with the provider and facilitate patient self-management and caregiver support of the patient. Telemedicine services often provides a broader access to medical care, eliminates transportation concerns, and increases comfort and familiarity for patients and their families when located in their own homes or other local environments.

However, telemedicine uses new communications technology for which there is little research supporting its effectiveness. For example, telemedicine services may not be as complete as in-person healthcare services because the healthcare provider will not always be able to observe subtle non-verbal communications such as a patient’s posture, facial expression, gestures, and tone of voice.

Telemedicine may transfer medical information through the use of interactive, real-time audio/visual technology (for example, video conferencing) or electronic data interchange (for example, computer-to-computer exchanges), or it may transfer medical information through the use of store-and-forward technology (for example, emails). While precautions are taken to secure the confidentiality of telemedicine services, the electronic transmission of medical information can be incomplete, lost or otherwise disrupted by technical failures. Additionally, despite such measures, the transmission and storage of medical information can be accessed by unauthorized persons, causing a breach of the patient’s privacy.

The expected benefits of using telemedicine include:

  • Improved and quicker access to medical care through reduced travel and visit time
  • Ability to access care from any location, and
  • More efficient medical evaluation and management

The potential risks associated with using telemedicine may include:

  • Delays in medical evaluation and treatment due failures of technology, such as a disconnected phone call
  • Information may be lost due to technical failures, and
  • In rare cases, a lack of access to complete medical information may result in adverse drug interactions, allergic reactions, or other judgment errors.

The inability to have direct, physical contact with your healthcare provider is the primary difference between telemedicine and in-person health care. The alternative to telemedicine is receiving care in a traditional in-person care setting.

To comply with California statute, you understand and acknowledge this NOTICE TO CONSUMERS. “Medical doctors are licensed and regulated by the Medical Board of California. (800) 633-2322”

Disclaimer: If you have a medical emergency, dial 911 immediately or go to your nearest emergency room.

Consent to Use Telemedicine

In receiving the Telemedicine Services I understand and agree:

  • I agree to provide complete and accurate medical history and I will update my medical health records with the office periodically, but no less than once a year.
  • I cannot use Telemedicine Services to get prescriptions for DEA controlled substances, nontherapeutic drugs and certain other drugs which may be harmful because of their potential for abuse.
  • I understand there is no guarantee that I will be treated by the Clinician. Clinicians reserve the right to deny care for potential misuse of Services or for any other reason if, in the professional judgment of the Clinician, the provision of the Service is not medically or ethically appropriate.
  • I agree that there is no guarantee that I will be given a prescription by the Clinician.
  • I am physically located in California. At the beginning of each telemedicine session, I will help my doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication.
  • My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.
  • I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor’s staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
  • My doctor believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
  • If my doctor believes at any time that another form of services (for example, a traditional in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule an in-person consultation with my doctor or refer me to a healthcare provider in my area who can provide such services.
  • I have the right to withdraw consent to the use of telemedicine services at any time and receive in-person healthcare services with my doctor.
  • I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.
  • I agree to have the necessary computer, equipment and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications.
  • The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
  • I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “auto-remember” usernames and passwords, or use my work computer for personal communications.
  • I understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation. It is my responsbility to prepare for my appointment by carefully following the instructions provided by my Clinician's office so that all communication can be accomplished within the telehealth system, including any photo uploads. If I bypass this encrypted system by emailing or texting / SMS'ing / iMessaging any photos or other health information, those communications may not provide me as high a level of privacy and security.
  • I understand that medical office personnel may also be participating in my visits to assist my doctor in documentation, handling orders for prescriptions, and similar support functions.
  • I have the right to access my medical information and obtain copies of my medical records in accordance with California law.
  • I understand that the telemedicine services provided to me will be billed to my health insurance company as appropriate and that I will be billed for any patient responsibility in accordance with my insurance.
  • I agree to pay all visit fees as determined by the office and in accordance with insurance contracts.
  • I understand that telemedicine coverage by insurance companies has increased during the pandemic but that coverage under my plan could discontinue and I still agree to pay the fees irrespective of whether my insurance includes coverage for this service or not.
  • I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction.

I understand the statements above and consent, on my own behalf or on behalf of my minor dependents, to receive Services.

I understand that I may access the Notice of Privacy Practices and acknowledge that I have been provided access to such Notice of Privacy Practices.

I read and understand the information provided in this document.