Texas Telemedicine Informed Consent Form Name * First Name Last Name Date of Birth * MM DD YYYY Date * MM DD YYYY Location of Patient * Introduction Telemedicine refers to remote electronic communications between a provider and a patient that includes electronic prescribing, scheduling and texting as well as videoconferencing and sharing educational material. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Expected Benefits - Improved access to medical care by enabling a patient to remain in his/her home or office. - More efficient evaluation and management of medical needs. - Reduced wait time and travel expenditures in receiving medical care. Possible Risks As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to: - In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate and timely medical decision making by the physician; - In very rare cases, despite security protocols that meet established industry standards, it is possible for any system to be breached, causing a breach of privacy of personal medical information. The risk is small, but it does exist; - In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgmental errors; Patient Responsibilities - I will not record any telemedicine sessions without written consent from my provider; - I will inform my provider if any other person can hear or see any part of our session before the session begins or as that person becomes present; - I understand that I, and not my provider, am responsible for the configuration of any electronic equipment on my computer or phone that is used in telemedicine. I am responsible for ensuring the proper function of all personal electronic equipment before my session begins. By submitting this form, I understand the following: 1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained which identifies me will be disclosed to researchers or other entities without my consent. 2. I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. 3. I understand that I have the right to inspect all information obtained in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee. 4. I understand that it is my duty to inform my doctor of any other healthcare providers involved in my medical/psychiatric care. 5. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. Patient Consent To The Use of Telemedicine * I have read and understand the information provided above regarding telemedicine. I hereby give my informed consent for the use of telemedicine in my medical care. Thank you! HIPAA Privacy Notice Back to Patient Forms
