I understand there are potential risks to this technology, including interruptions, possible unauthorized access, or other unexpected difficulties.
I understand video calling technology will be used to deliver this service; however, I am also aware the appointment can be conducted via voice call if technical difficulties arise.
I understand my provider or I can discontinue the appointment if the connections are not adequate.
I understand this service will not be the same as direct care appointment due to the fact I will not be in the same room as my provider.
I understand persons, other than my provider, may be present during my appointment for the purpose of service delivary, group member participation, or operation/troubleshooting/fixing of the video or audio equipment. Anyone present during the appointment is expected to maintain full confidentiality of all information. I further understand I will be informed of their presence and have the right to request the following:
Omit specific details of my medical history/physical examination that are personally sensitive to me;
Ask non-medical personnel to leave the telemedicine examination room; and/or
Terminate the appointment at any time
I understand that the laws that protect privacy and confidentiality of medical information also apply to telehealth.
I understand it is in my best interest to protect my privacy as well as other’s that when attending telehealth sessions I am in a private, non-public location where my participation in this telehealth appointment will not expose my or anyone elses’ private health information to potential exposure.