I, (Patient) hereby consent to engage in Telehealth with my Physician at David S. Weingarden MD & Associates P.C. (Physician).

I understand that Telehealth is a mode of delivering health care services, via communication technologies (e.g. Internet or video phone call) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

I understand that I can see my physician in-person at the physician’s office and that is generally the preferred way to provide medical care, as it allows my physician to be able to readily perform a physical exam on all areas relative to my concerns. However, I understand that Telehealth has been found to be effective in treating a wide range of medical, mental and emotional issues and in those situations, is as effective as an in-office visit.

By signing this form, I understand and agree to the following:

1. I understand that there is no guarantee that Telehealth is effective for all individuals. Therefore, while I may benefit from Telehealth, results cannot be guaranteed or assured.
2. I understand that if my physician believes I would be better served by an in-person office visit, my physician will discuss this with me and refer me to schedule in-person services as needed. If such services are not possible because of distance or hardship, I will be referred to other physicians who can provide such services.
3. I understand that I have a right to confidentiality about my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in-person medical care.
4. I understand that there are risks associated with participating in Telehealth including, but not limited to:
   1. that my physician visit and transmission of my treatment information could be disrupted or distorted by technical issues or interrupted or accessed by unauthorized persons,
   2. that the electronic storage of my treatment information could be accessed by unauthorized persons.
   3. that Telehealth may not be as effective or provide the same results as in-person medical care.
   4. that miscommunication between myself and my physician may occur via Telehealth.
   5. that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions.
5. I understand that at the beginning of each Telehealth session my physician will verify my identity and I understand that some Telehealth platforms allow for recordings of the session and that my physician may record the sessions for documentation of the visit.
6. I agree to the fees charged for Telehealth with my physician and agree that my physician will bill my insurance plan for Telehealth and that I will be billed for any portion that is the patient’s responsibility (e.g. co-payments).

I have read and understand the information provided above and understand that I have the right to have all my questions regarding this information answered to my satisfaction.