Telemedicine Informed Consent Form

Informed Consent for Telemedicine Services

  • Telemedicine involves the use of electronic communications to enable your medical care providers at different locations to share individual patient medical information for the purpose of improving patient care. The telemedicine visit is done by way of a two way video link through which the medical care provider can see and hear the patient. 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 and sound and video files. 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.
    Expected Benefits:
    • Improved access to medical care by enabling a patient to remain at a remote site while the medical care provider interviews the patient, obtains test results and consults from healthcare practitioners at distant/other sites.
    • Limits the exposure of both patient and staff to communicable diseases.
    • More efficient medical evaluation and management.
    Possible Risks:

    As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

    • Unlike a traditional medical visit, the physician or other health provider does not have the use of touch or smell, and the visit may not be equal to a face to face visit. Vital signs are not obtained and an exam cannot be performed.
    • Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the medical care providers.
    • 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.

    By signing this form, I understand the following:

    1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
    2. 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.
    3. 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 physician has explained the alternatives to my satisfaction.
    4. 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

    I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

    I hereby authorize Pulmonary & Sleep Specialists, P.C. to use telemedicine in the course of my diagnosis and treatment.

  • Signature of Patient (or person authorized to sign for patient):
    MM slash DD slash YYYY
  • If authorized signer, what is your relationship to patient?