Informed Consent for Telehealth Services
Telehealth consultation uses electronic platforms to facilitate communication between healthcare providers and patients. The purpose of telehealth services is to improve patient care by providing access to physicians. Telehealth services could include patient chart review and compilation, prescriptions, appointment scheduling, physician appointments, information sharing and patient education. These services could include any of the following: live audio and visual, live video, interactive audio, output data, images and health records.
Whatever electronic communication methods are employed will incorporate network and software security designed to protect patient confidentiality and information protection.
Telehealth consultations are designed to supplement and not replace care given by your primary care physician or healthcare provider. You accept responsibility for your own medical care and for necessary continuity received through a relationship with a primary care physician apart from your telemedicine physician.
Potential Benefits of Telehealth Consultation:
- Instant access to care when you are at home. This could include the ability to obtain your records and test results from other sites.
- Improved care and health management.
- Access to specialists when needed.
Potential Risks of Telehealth Consultation:
- Electronic or equipment failure or delays could affect the outcome of the consultation. Delays in evaluation, diagnosis and treatment could result in negative impacts upon the patient’s health.
- It is possible that the telemedicine physician may decide that the information gleaned through electronic means is insufficient and the consultation may be ended or cancelled with the recommendation for you to meet in person with your primary care physician or healthcare provider.
- It is possible that the lack of access to full medical records may result in adverse drug reactions or other medical diagnostic errors.
- Rarely, security measures could be breached and private healthcare information may be compromised.
In the event of an adverse reaction to the treatment or inability to complete the consultation due to technical difficulties please contact email@example.com. For follow-up care, consult your primary care physician. For medical emergencies, dial 9-1-1 and go to your nearest emergency room.
By checking the Informed Consent document, you acknowledge that you understand and agree with the following:
- I hereby consent to receive medical services through telehealth electronic technology. I understand that go Cover and its affiliates are the platform by which I can receive telehealth services, but go Cover itself does not provide medical advice or assistance. I acknowledge that telehealth services do not replace a relationship with my primary care physician or healthcare provider and I will continue to receive in-person care when needed. Additionally, I accept the judgment of the independent physician to determine if a telehealth consultation is right for me.
- I hereby acknowledge that I have selected an independent physician on the go Cover platform and am responsible for reviewing that physician’s credentials.
- Knowing that state and federal laws protect the privacy of patient information, I know go Cover is not responsible for any breaches of privacy. I also know that go Cover will take reasonable steps to ensure a safety protocol is in place. I further understand that telehealth communication involved the electronic transmission of my personal healthcare information. Other healthcare providers may receive my healthcare information when looking for additional and qualified opinions.
- As with any electronic conveyance, I understand there is a risk of electronic and technical failures. These could occur at any time during the telehealth visit and are beyond the control of go Cover. I agree to hold go Cover harmless for any medical impacts that may result from delays in diagnosis and treatment.
- As a patient using telehealth communication, I have the right to withhold or withdraw my consent to use this platform during the course of my care without affecting my ability to obtain future care or treatment. I may end the use of telehealth services at any time without notice. I understand that medical emergencies need prompt care and not telehealth consultations and I will dial 9-1-1 or have someone transport me to the nearest emergency room.
- There are options available to me other than telehealth consultations, such as in-person physician’s visits. I understand that my telehealth visit may require additional testing or procedures that cannot be obtained during an online consultation.
- I acknowledge that there are no guarantees of benefits resulting from the use of telehealth visits.
- My medical information may be shared with others for scheduling and billing purposes or for additional consultations, labs and tests. In the case of additional consultations, I reserve the right to omit sensitive details, ask non-medical personnel to be omitted from the consultation or end the call at any time.
- Prescriptions are not guaranteed with telehealth consultations and I acknowlege that I may need an in-person visit with my primary care physician to obtain a prescriptions. I understand that narcotics for pain relief are closely controlled and will not be given through telehealth consulltations.
- A copy of my medical records is my right and I can request them at any time. I understand I may need to pay a reasonable shipping and handling fee.
Additional State-Specific Agreements: Telehealth communications between physicians and users are governed by specific state rules. These rules are constantly changing. It is up to each individual to know the rules of that state and to understand the rights therein.
I have read this document carefully, and understand the risks and benefits of the telehealth consultation. I understand that my primary care physician may receive a copy of my telehealth medical records. I have had my questions regarding the distance examination explained and I hereby give my informed consent to participate in a telehealth consultation under the terms described herein.
By checking the box for Informed Consent of Telehealth Consultation, I hereby state that I have read, understood, and agree to the terms of this document.