By using our services and signing the form, before submitting an online medicine form, You, the patient or authorized patient representative, understand and agree with the following: Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants and other healthcare providers who are part of our clinical care team. Information entered, saved, or transmitted may be used for diagnosis, therapy, follow-up and/or education. Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:
• Progress reports, assessments, or other intervention-related documents
• Bio-physiological data transmitted electronically
• Videos, pictures, text messages, audio and any digital form of data.
The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies you will not be given to anyone without your consent except for the purposes of treatment, education, billing and healthcare operations. By agreeing to use the telehealth/telemedicine services, you are consenting to physician(s) referred to you by EssentialTelehealth.co, sharing your protected health information with certain third parties as more fully described in the EssentialTelehealth.com Privacy Policy and Terms Of Services. You understand, agree, and expressly consent to EssentialTelehealth.co and the physicians it refers to obtaining, using, storing, and disseminating to necessary third parties, information about you, including your image, as necessary to provide the telehealth/telemedicine services. As with any Internet-based communication, You understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Individuals other than our clinical care team or consulting providers may also be present and have access to your information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies. Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient or care team. You hereby release and hold harmless EssentialTelehealth.co and all members of the care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service. You understand and agree that the health information You provide at the time of your telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of your evaluation and treatment at the time of your telehealth/telemedicine visit, and that such professionals may not have access to your full medical record or information held at EssentialTelehealth.co.
Telehealth Consent v.08.30.2021 2 ~ You understand that You will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for your medical care through the telehealth/telemedicine visit. You understand that EssentialTelehealth.co only provides telemedicine services and You have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time.
You agree that all of Your questions have been answered to Your satisfaction and You hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.
By signing the box in the online medical form provided, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.