Telemedicine Consent Form

Telemedicine is the delivery of healthcare services through the use of technology when the healthcare provider and patient are not in the same physical location. Electronically transmitted information may be used for diagnosis, therapy, follow-up, and/or patient education—and may include: patient medical records, medical images, interactive audio and video, and output data from medical devices and sound and video files.

The interactive electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data. This will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Benefits include improved access to medical care by enabling a patient to remain at a remote site; and obtaining the expertise of a distant specialist, if necessary. Risks include poorly transmitted information and images, due to any technical or software issues; potential breach of personal or medical information (though encryption and security protocols are enacted to protect against this); and a potential lack of access to complete medical records.

By signing this form, I understand and agree to the following:
1. The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. No information obtained during a telemedicine encounter that identifies me will be disclosed to other entities without my consent.
2. I have the right to withhold or withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that this will not affect any care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled.
3. A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician or medical practice representative has explained the alternative care methods to me.
4. I may expect the anticipated benefits from the use of telemedicine in my care, but no results can be guaranteed or assured.

I have read, fully understand, and consent to the information provided above regarding telemedicine. By using an electronic signature, I demonstrate my acceptance of the information above. My electronic signature is as legally binding as my handwritten signature.

Patient or Guardian (where applicable) Signature:

Please sign electronically below.

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