Purpose

The purpose of this form is to obtain your consent for a telemedicine consultation with a physician at Peninsula GI Medical Group. The purpose of this consultation is to assist in the diagnosis or treatment of a gastrointestinal or liver disease.

Introduction

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. The information may be used for diagnosis, therapy, and/or follow-up; 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 in his/her office (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.

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:

• 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 or allergic reaction or other judgment error;

Financial Resposibility

Telemedicine provided by physicians at Peninsula GI Medical Group is a service that may not be covered by your insurance. Consultations and follow up visits via audio/video devices may not be considered a covered benefit under your health insurance. If your insurance plan determines you are ineligible for a telemedicine visit you will be billed directly for your visit.

BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:

• 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,
• 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,
• No form of video or audio recording is permitted by either the patient or the physician during a telemedicine consultation. All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without consent,
• I understand that I have the right to inspect all information obtained in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee,
• 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.
• I attest that I am located in the state of California and will be present in the state of California during all telehealth encounters.
• I understand it is my responsibility to protect my own privacy while participating in a telemedicine session and that I should ensure the location I choose is quiet and secure from anything that may compromise my privacy.
• I acknowledge that I have been informed in advance of receiving these services that these services may not be covered by my health insurance plan. I have chosen to receive these services and understand that I will be financially responsible for the charges (Patient’s Initials).

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 Agree

I hereby authorize (name of Physician) to use telemedicine in the course of my diagnosis and treatment.