TelewellnessMD Informed Consent

 

Introduction of TelewellnessMD (We):

As a patient receiving wellness services through TelewellnessMD health technologies, I understand:

1. We provide the delivery of health services using interactive technologies (use of audio, video or other electronic communications) between a healthcare provider and a patient who are not in the same physical location.   
2. We use interactive technologies and software security protocols to protect the confidentiality of patient information transmitted via electronic means.  These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional compromise.

 

Software Security Protocols:

 

Benefits & Limitations:

 

Technology Requirements:

 

Exchange of Information

1. The exchange of information will be provided through electronic means. 
2. During my health consultation, details of my medical history and personal health information may be disclosed to health care professionals through the use of technology (including but not limited to video, phone, text, apps and email).

 

Local Healthcare providers:

 

Self-Termination:

 

Risk of Technology:

 

Emergency Protocol:

 

Disruption of Service:

 

Healthcare provider Communication:

1. My healthcare provider may utilize alternative means of communication in the following circumstances:
   1. Telephone contact  
   2. SMS text message contact
   3. Email contact
2. My healthcare provider will respond to communications and routine messages within 48 hours.

 

Patient Communication:

1. It is my responsibility to maintain privacy on the patient end of communication.  I have read the notice of privacy practices.
2. I will take precautions to ensure that my communications are directed only to TelewellnessMD and their designated individuals.

 

Storage:

 

Laws and Standards:

 

Electronic Transmission of Information:

 

Mobile Application:

1. It may also mean that my private health information may be transmitted from my healthcare provider’s mobile device to my own or from my device to that of my healthcare provider via email or an “application” (abbreviated as “app”).  
2. I understand that a variety of alternative methods of wellness healthcare may be available to me, and that I may choose one or more of these at any time.   Choosing to initiate a conversation outside of the TelewellnessMD platform may compromise my privacy.

 

Equipment:

 

Identification:

 

Electronic Presence:

 

Limitations:

 

Risks:

1. I understand that telehealth is a new delivery method for professional services, in an area not yet fully validated by research, and may have potential risks, possibly including some that are not yet recognized.
2. Among the risks that are presently recognized is the possibility that the technology will fail before or during the consultation, that the transmitted information in any form will be unclear or inadequate for proper use in the consultation(s), and that the information may be intercepted by an unauthorized person or persons.
3. In rare instances, security protocols could fail, causing a breach of privacy of personal health information (see Notice of Privacy Rights).    My health information is protected by law.

 

Discontinuing Care:

1. I understand that at any time, the consultation can be discontinued either by me or by my authorized designee or by my healthcare provider.
2. I further understand that I do not have to answer any question that I feel is inappropriate or whose answer I do not wish persons present to hear; that any refusal to participate in the consultation or use of technology will not affect my continued treatment and that no action will be taken against me.
3. I acknowledge, however, that diagnosis depends on information, and treatment depends on diagnosis, so if I withhold information, I assume the risk that a diagnosis might not be made or might be made incorrectly and my treatment might be less successful than it otherwise would be, or it could fail entirely.

 

Limits of Confidentiality:

 

Alternatives:

 

Records:

1. I understand that my TelewellnessMD consultation(s) may be recorded and stored electronically as part of my medical records.  I understand that consultations, tests results, and disclosures will be held in confidence subject to state and/or federal law.
2. I understand that I am ordinarily guaranteed access to my records and that copies of records of consultation(s) are available to me on my written request.
3. I also understand, however, that if my healthcare provider, in the exercise of professional judgement, concludes that providing my records to me could threaten the safety of a human being, myself or another person, he or she may rightfully decline to provide them.  If such a request is made and honored, I understand that I retain sole responsibility for the confidentiality of the records released to me and that I may have to pay a reasonable fee to get a copy.
4. Additionally, I understand that my records may be used for program evaluation, education and research and that I will not be personally identified if such a use occurs.
5. I hereby authorize these disclosures to take place without prior written consent.

 

Compensation:

 

Contact Information:

 

Emergency Care:

1. I acknowledge, however, that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person; I am not to seek a TelewellnessMD consultation.
2. I agree to seek care immediately through my own local healthcare provider or at the nearest hospital emergency department or by calling 911.

 

Final Agreement:

1. I have read this document carefully and fully understand the benefits and risks.  I have had the opportunity to ask any questions I have and have received satisfactory answers.
2. With this knowledge, I voluntarily consent to participate in the TelewellnessMD consultation(s), including but not limited to any care, treatment, and services deemed necessary and advisable, under the terms described herein.