This document contains important information about the telehealth services of your licensed dermatologist, or other licensed health care providers (such as nurses, nurse practitioners, physicians assistants, et cetera) through the Telehealth Group, PLLC and its affiliated entities and related practices (collectively referred herein to as “Telehealth Group”). This document is intended to inform you of the benefits, risks and alternatives associated with telehealth dermatology services. Please read it carefully and discuss any questions you may have with your dermatologist.
What is Telehealth?
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care and allowing the practitioner to provide care and treatment in accordance with the practitioner’s scope of practice. The dermatologist-prescribed telehealth services (“teledermatology”) offered by Telehealth Group will consist of telehealth services and may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.
The electronic communication systems we use 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.
Telehealth Group physicians (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
Potential benefits of using teledermatology include improved access to care by enabling you to remain in your home while the Telehealth Group provider consults and obtains test results at distant/other sites, more efficient care evaluation and management, obtaining expertise of a specialist as appropriate who may not be available for a face-to-face consultation, and time flexibility. However, there are no guarantees about the results or outcomes of teledermatology.
By checking the box below, you are indicating that you understand that there are potential risks to using teledermatology, including without limitation:
Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies;
The potential that visual or auditory or other cues that a provider may pick up on in-person may not be picked up by the treating provider over two-way audio or video;
In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor;
The possibility that the transmission of your health information could be disrupted or distorted by technical failures
Risks related to a patient withholding key medical information or records;
In very rare events, security protocols could fail, causing a breach of privacy of personal medical information; or
In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
Further, please understand that there may be uncertainty and inaccuracy inherently associated with telehealth. By consenting to telehealth services, you accept that the “physical exam” portion of the consultation(s), if any, will be done via pictures, telephone consultation, two-way audio/video consultation, questionnaire, app data and other good faith methodology applied when not conducting an in-person physical exam.
If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact Telehealth Group at firstname.lastname@example.org
By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:
I hereby consent to receiving Telehealth Group’s services via telehealth technologies. I understand that Telehealth Group and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Telehealth Group provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
I have been given an opportunity to select a provider from Telehealth Group prior to the consult, including a review of the provider’s credentials.
I understand that my care will be rendered by, and if applicable prescriptions written by, one or more licensed providers. Notwithstanding the tradename of the entity, the licensed provider(s) may be professionals who are not dermatologists, such as a licensed general-practitioner physician, or a nurse practitioner or a physician assistant, working under a collaboration agreement with a licensed physician.
I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Telehealth Group will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state. However, I understand that in rare circumstances, security protocols may fail, causing a breach of my private information. The alternative to a teledermatology consultation is a face-to-face visit with a dermatologist. I understand that I may benefit from teledermatology, but the results are not guaranteed. If my dermatologist believes I would be better served by another form of therapeutic services (such as a face-to-face visit), I will be referred to those services in my area.
I understand there is a risk of technical failures during the telehealth encounter beyond the control of Telehealth Group. I agree to hold harmless Telehealth Group for delays in evaluation or for information lost due to such technical failures.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that teledermatology does not provide any emergency services, and if I am experiencing a medical emergency, that I should dial 9-1-1 immediately or go to the nearest emergency room. I further understand that the Telehealth Group providers are not able to connect me directly to any local emergency services.
I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Telehealth Group provider (e.g. labs or bloodwork).
I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Telehealth Group provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
I further acknowledge and understand that I will need to provide a full and accurate medical history, including any pre-existing health conditions, so that my practitioner can determine an appropriate treatment plan. Moreover, I acknowledge and understand that my teledermatology practitioner will determine whether teledermatology is appropriate for me based on specific condition and needs.
Use of teledermatology is voluntary and not required. You have the right to withhold or withdraw your consent to a teledermatology consultation at any time before and/or during the consult without affecting your right to future care, treatment, or any program benefits. You also have the right to refuse telehealth services and to be apprised of alternatives to such services, including any delays in service, need to travel, or risks associated with not having the services provided by telehealth. However, please note that the withdrawal of such consent may cause Telehealth Group and its Providers to discontinue care. You have the right to access your medical information in accordance with applicable law.
Additional State-Specific Consents: The following consents apply to users accessing the Telehealth Group website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (AK Stat. 08.64.364).
Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12- 2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (A.R.S. § 36-3602).
Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (C.G.S.A. § 19a-906).
D.C.: I have been informed of alternate forms of communication between me and a physician for urgent matters. (17 DCMR § 4618.10).
Kentucky: If I am a Medicaid recipient, I recognize I have the option to refuse the telehealth consultation at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid benefit to which I am entitled. I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. (KY Admin. Regs. Tit. 907, 3:170).
Louisiana: I understand the role of other health care providers that may be present during the consultation other than the Telehealth Group provider. I further understanding that I may decline to receive medical services via telemedicine and may withdraw from such care at any time. (46 La. Admin. Code Pt XLV, § 7511).
Maryland: I understand that dissemination of image or information identifiable to me shall not be disseminated to other entities without my consent, unless there is an emergency preventing the practitioner from obtaining such consent. (Code of MD Reg. 10.09.49.09). Regarding audiologists, speech language pathologists, and hearing aid dispensers, I recognize the inability to have direct, physical contact with the patient is a primary difference between telehealth and direct in-person service delivery. The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Code of MD Reg. 10.41.06.04).
Nebraska: If I am a Medicaid recipient, I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. (NE Revised Stat. 71-8505; NE Admin. Code Tit. 471, Ch. 1).
New Hampshire: I understand that the Telehealth Group provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).
New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. (NJ Rev. Stat. § 45:1-62).
Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services.
Rhode Island: If I use e-mail or text-based technology to communicate with my Telehealth Group provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Telehealth Group provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines).
South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code 1976 § 40-47-37).
Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment if I am a Medicaid recipient.
Texas: I understand that my medical records may be sent to my primary care physician. (V.T.C.A., Occupations Code § 111.005).
Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via Telehealth Group does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (VT Stat. Ann. § 9361).
Note, these state-specific telehealth consent rules are constantly changing and being updated/revised. One approach is to have us update this form periodically to revise for new state specific changes. Another approach is to eliminate this state-specific section and just use an informed consent which substantially complies with the spirit and purpose of the rules, albeit might not meet each state’s specific language.
I have read this document carefully, and understand the risks and benefits of the teledermatology consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a teldermatology consultation under the terms described herein.
By checking the Box containing "INFORMED CONSENT FOR TELEDERMATOLOGY SERVICES" I hereby state that I have read, understood, and agree to the terms of this document.
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