Royal Oak Pediatrics: Consent for Telemedicine Services

What is telemedicine?
Telemedicine is the delivery of healthcare services through the use of some form of technology when the health care provider and the patient are not physically in the same location.

During a telemedicine visit, electronically transmitted information will be used for assessment, diagnosis, intervention, follow up and/or patient education. This information may include (but not limited to) discussion of past medical history/medical records, current medical issue, medical images, remote physical assessment, live two way video/audio call, and any output data from medical devices and sound and video files.

The systems used for the telemedicine visit are HIPAA compliant and incorporate network and software security protocols to protect patient confidentiality, and include measures to safeguard any data to ensure its integrity against intentional or unintentional corruption. Video and audio of the telemedicine visit are not saved, visit notes will be charted in the current electronic medical record utilized by the office.

All existing laws regarding access to medical information and copies of your medical records apply, please note that the audio and video from telemedicine visits are not saved.

You may withhold or withdraw consent for telemedicine at any time, without affecting your right to future care or treatment.

The provider has the right to decide at any point that an in person visit is required for further treatment of the issue at hand at any time.

Benefits to telemedicine include improved access to medical care enabling the patient to remain at home and receive appropriate care. Potential risks include (but are not limited to): information transmitted may not be sufficient for appropriate medical decision making (at which point the provider may require an in person appointment), delays in medical evaluation/treatment due to technical issues, and the provider will not be able to provide direct medical treatment to the patient through the use of telemedicine equipment nor arrange for any emergency care if the patient requires it.

It is the responsibility of the Patient, Parent, or Guardian’s to make any payment towards this service (such as a copay or insurance deductible).

I , agree to participate in a telemedicine visit.

Click here to indicate that you have read and agree to the terms of the Consent for Telemedicine Services.

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