Consent for Telehealth Care

Telehealth involves the use of electronic communications to enable providers at different locations to share individual client information for the purpose of improving client care. The information may be used for diagnosis, therapy, follow-up and/or education.

By signing this form, I Understand the following:

  1. I understand that the laws that protect privacy and theconfidentiality of health information also apply totelehealth, and that no information obtained in theuse of telehealth which identifies me will be disclosedto researchers or other entities without my consent.

  2. I understand that I have the right to withhold orwithdraw my consent to the use of telehealth in thecourse of my care at any time, without affecting myright to future care treatment.

  3. I understand that I have the right to inspect allinformation obtained and recorded in the course of atelehealth interaction and may receive copies of thisinformation for a reasonable fee.

  4. I understand that a variety of alternative methods ofhealth care may be available to me, and that I maychoose one or more of these at any time. My providerhas explained the alternatives to my satisfaction.

  5. I understand that telehealth may involve electroniccommunication of my personal health information toother practitioners who may be located in other areas,including out of state.

  6. I understand that I may expect the anticipatedbenefits from the use of telehealth in my care, butthat no results can be guaranteed or assured.

Electronic systems used will incorporate network and software security protocols to p protect the confidentiality of client 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 care by enabling a patient toremain in his/ her provider’s office (or at a remotesite) while the provider obtains test results andconsults from practitioner =s at distant/ other sites.

  • More efficient patient evaluation and management.

  • Obtaining expertise of a distant specialist.

Possible Risks:

  • There are potential risks associated with eth use of telehealth. These risks include, but may not be limited to:

  • In rare cases, information transmitted may not besufficient (e.g., poor resolution of images) to follow forappropriate decision making by the providers andconsultant(s);

  • Delays in evaluation and treatment could occur dur todeficiencies or failures of the equipment;

  • In very rare instances, security protocols could fail,causing a breach of privacy of personal healthinformation;

  • In rare cases, a lack of access to complete healthrecords may result in interactions or allergic reactionsof other judgment errors;