You hereby consent to engaging with Medical Health 360 LLC as part of your and your child’s wellness. I understand that telemedicine includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves communication of my medical/mental information both orally and visually, to health care practitioners located in and outside of the State of New York.

 

I understand that I have the following rights with respect to telemedicine: 

1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

2.) The laws that protect my confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

 

I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

 

3.) I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my physician:

  1. The transmission of my medical records could be disrupted or distorted by technical failure.

  2. The transmission of my medical information could be interrupted by unauthorized persons; although this is rare. The electronic storage of my medical information could be accessed by unauthorized persons; although this is rare.

  3. Limitations of the treatment provided via telemedicine, including but not limited to lack of a complete physical exam.

 

I understand that that telemedicine based services and care may not be as complete as face-to-face services. I am expected to maintain proper follow up appointments with my primary care physician in conjunction with my telemedicine services as these sessions do not replace my primary care.  I understand that if my physician believes I would better be better served by another form of services, including face-to-face services by another physician, I will be referred to such services.

 

4.) I understand I may benefit from these telemedicine services, but that results cannot be guaranteed or assured.

5.) I understand that I have a right to access my medical information, and copies of medical records in accordance to New Jersey/New York state law.

6.) I understand that if I have an emergency, I will need to call '911' or report to the nearest emergency department. 

 

I have read and understand the information provided above. I have been advised of all the potential risks, consequences, and benefits of Telemedicine. I also understand that to help improve privacy/confidentiality, I will not record any of the video/audio sessions. I have also been made aware, and agree to the scheduling and billing procedures. I have discussed the above with my physician, and all of my questions regarding this form and the telemedicine consultation, as well as follow up appointments have been answered to my satisfaction.  

Telemedicine Consent

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