Telemedicine Authorization and Consent Form

Telemedicine Session Patient Authorization and Consent Form

Telemedicine lets a doctor or other healthcare provider care for you, even when you cannot see him or her in person. The doctor uses the Internet or other technology to:

  • Give you advice
  • Give you an exam
  • Consult for a procedure
  • Prescribe medications

Telemedicine is more than a phone call, an email, a fax, or an online questionnaire.

You and your healthcare team must decide if your health problem can be helped with telemedicine. The team and others involved in your care will make a plan for your care using telemedicine. This will also include a plan in case you have an emergency during the telemedicine session.

If the patient is a minor child, the telemedicine provider will explain to the parent how a telemedicine exam is different from an in-person exam. He or she will also explain if a complete exam of the child is possible.

Your Telemedicine Session

During your telemedicine session:

  • The provider and the staff will introduce themselves.
  • When starting a session, you may be asked to confirm the state you are in and the state where you live.
  • The provider may talk to you about your health history, exams, x-rays, and other tests. Other providers may take part in this discussion.
  • A visual and/or partial physical exam may take place. This may happen by video, audio, and/or or with other technology tools. A nurse or other healthcare staff may be in the room with you to help with the exam.
  • A report of the session will be placed in your medical record. You can get a copy from your provider.

All laws about the privacy of your health information and medical records apply to telemedicine. These laws also apply to the video, photo, and audio files that are made and stored.

Risks and Common Problems

Many patients like telemedicine because they do not have to spend time and money on travel to see a certain healthcare provider in person. Also, they can see a provider who they might not be able to see otherwise.

Technology can make getting health care easy, but there can also be problems:

  • If there is an equipment or Internet problem, your diagnosis or treatment could be delayed.
  • Records or images that are taken and sent may be poor quality. This can delay or cause problems with your diagnosis or treatment.
  • If there is a technology problem, the information from your session may be lost. This would be outside the control of your doctor and the telemedicine provider.
  • Without a hands-on exam, it may be hard to diagnosis your problem.

More Facts

A main goal of telemedicine is to make sure that you get good, personal health care, even though you are not seeing a provider in person.

Some states may require you to have a face to face visit first and a yearly visit with your doctor before telemedicine treatment can happen.

Telemedicine providers must follow the same rules for prescribing drugs just as they would for an office visit.

Having a telemedicine session is your choice. Even if you have agreed to the session, you can stop your medical records from being sent – if this has not happened yet. You can stop the session at any time. You can limit the physical exam.

You will be told about all staff who will take part in the session. You can ask that any of these people leave the room to stop them from seeing or hearing the session. It is up to you to make sure the setting for your session is private. It should only include people who you are willing to share health information with. Your telemedicine provider can ask that people with you leave the room to make sure your session is private.

Your session may end before all problems are known or treated. It is up to you to get more care if your health problems do not go away.

You will be told how long it might take to respond to your emails, phone calls, or other types of messages.

Patient Acknowledgment

This form gives you facts about and risks of telemedicine sessions. By providing verbal agreement, you agree that you have read, understand, and agree with these terms.

I also confirm by giving my consent that:

  • I have been told the name and credentials of my telemedicine provider
  • I have been able to ask questions about telemedicine sessions
  • All of my questions have been answered
  • I understand no guarantees have been made about success or outcome
  • I agree to take part in a telemedicine session.

REQUEST AN APPOINTMENT

Request an Appointment

* All indicated fields must be completed.
Please include non-medical questions and correspondence only.

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