1- I understand that Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for improving patient care.
Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
– Patient medical records.
– Medical images.
– Live two-way audio and video.
Output data from medical devices, audio/video files, and electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data. They will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
2- The expected benefits are as follows:
– Improved access to medical care by enabling me to remain in my home (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
– More efficient medical evaluation and management.
– Obtaining expertise of a distant specialist.
3- I have been informed with the possible risks as any medical procedure, include, but may not be limited to:
– In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).
– Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
– In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
– In rare cases, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.
4- I understand that the laws that protect the privacy and the confidentiality of medical information also apply to Telemedicine and that no information obtained in the use of Telemedicine that identifies me will be disclosed to researchers or other entities without my consent.
5- I understand that I have the right to withhold or withdraw my consent to the use of Telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
6- I understand that I have the right to inspect all information obtained and recorded in the course of a Telemedicine interaction, and may receive copies of this information for a reasonable fee.
7- I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My ophthalmologist has explained the alternatives to my satisfaction.
8- I understand that Telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
9- I understand that it is my duty to inform my ophthalmologist of electronic interactions regarding my care, which I may have with other healthcare providers.
10- I understand that I may expect the anticipated benefits from the use of Telemedicine in my care, but that no results can be guaranteed or assured.
Patient Consent to the Use of Telemedicine
By paying for the session, I confirm that I have read and understood the information provided above regarding Telemedicine, have discussed it with my physician or such assistants as may be designated, and all my questions have been answered to my satisfaction. I hereby give my informed consent to the use of Telemedicine in my medical care as well as authorizing ALJ Hospital physicians to use Telemedicine in the course of my diagnosis and treatment.
