Tele-health Informed Consent Form
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:
- 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.
- 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.
- 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.
- I understand that there are risks associated with participating in Telehealth including, but not limited to:
- 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,
- that the electronic storage of my treatment information could be accessed by unauthorized persons.
- that Telehealth may not be as effective or provide the same results as in-person medical care.
- that miscommunication between myself and my physician may occur via Telehealth.
- 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.
- 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.
- 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.