PIPPEN HEALTH OF TEXAS, PC
INFORMED CONSENT REGARDING USE OF TELEMEDICINE SERVICES
PIPPEN HEALTH OF TEXAS, PC (“PC”)
Attention: Sean Cole, MD
Type of Provider: Physician
The purpose of this form is to provide you with information about telemedicine and to obtain your informed consent to participate in a telemedicine health service as part of your medical care.
NATURE OF TELEMEDICINE
Telemedicine involves the use of electronic communications to enable a healthcare provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telemedicine allows the patient and provider to establish a relationship, much as they would during a traditional face-to- face appointment.
YOUR TELEMEDICINE VISIT
Your telemedicine encounter with PC may include interaction through and with the use of the internet, video chat, audio communications, review of images and medical history submitted by you, and diagnoses, as well as related technologies known as “store-and-forward.” Our providers are also always available for follow-up questions and concerns by phone and email.
The benefits of telemedicine include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. In some circumstances, telemedicine can increase efficiency in evaluations, diagnoses, consultations, and treatment.
The potential risks associated with the use of telemedicine are rare, but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to patient’s failure to provide complete medical information or records.
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS PC ITS EMPLOYEES, AGENTS, DIRECTORS, AFFILIATES, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO PC’S NEGLIGENCE.
Alternative methods of care may be available to you, such as in-person services or care from yoru primary care provider. Your telemedicine provider will explain any such options to you, and you may choose that alternative at any time.
FOLLOW-UP CARE; EMERGENCY SITUATIONS
In some situations, telemedicine is not an appropriate method of care. If there is an urgent situation, if you have an adverse reaction, if a technical failure prevents you from communicating with your telemedicine provider, or if you believe telemedicine will not provide sufficient safety and quality, you should contact PC as indicated below. If the contacts listed below are unavailable, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. If the situation is an emergency, call 911.
Name: Sean Cole, MD
YOUR PRIVACY RIGHTS
PC uses network and software security protocols to protect the confidentiality of your patient health information, including for example your medical record, EMR, imaging, and personal financial data. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in PC’s Notice of Privacy Practices.
By signing this form, I understand the following:
Telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to a patient when the patient is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions and any medications I am taking to my telemedicine provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telemedicine is appropriate for me at this time, based on the condition being diagnosed and/or treated. I understand that I may benefit from telemedicine, but that results cannot be guaranteed. My provider will inform me who will be present at the provider’s location during the telemedicine service and I have the right to exclude anyone from being present, if I so choose. I further understand that I have the right to object to the use of a telemedicine service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled. I understand that I will be informed of the cost of my telemedicine encounter prior to the start of my visit.
Further, I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine and I agree that PC may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary. I have the right to inspect and obtain copies of all information received and recorded during any telemedicine session, subject to the policies of the medical providers involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules.
I have read and understand the information above and all of my questions have been answered to my satisfaction.
All photos on the website/app are models and not actual patients unless expressed otherwise.
I consent to Sean Cole and PC providing services to me via telemedicine.
By checking the box, I understand and consent to the foregoing acknowledgements and disclosures.