Tele-medicine Consent I understand that my health care provider, wishes me to engage in a telemedicine consultation with Dr. Wesley Nahm (Medical Director) or his delegated Mid-level if the need presents itself. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation. I understand that this consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider(s) or myself can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation; I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection. I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby consent to participate in a telemedicine visit under the terms described here in. If you have any questions regarding telemedicine or the above, ask now before signing this consent form. Patient Name(Required) First Last HiddenDate MM slash DD slash YYYY Patient Signature(Required)CAPTCHA
