1. Purpose
The purpose of this Sample Telemedicine Consent Form is to collect the patient's consent to participate in telemedicine consultation, and inform the patient about his or her rights, use of personal and medical information, risks, and benefits of telemedicine consultation.
2. Telemedicine Consultation
Treatment of the patient is conducted via interactive telecommunication technology such as online videoconference visits. The aim of using this technology is to provide complete remote treatment to patients.
3. Confidentiality
Patient information is kept private and protected by the existing federal and state laws. The healthcare facility is using HIPAA compliant videoconference tools and software to provide telemedicine consultation.
Existing laws regarding patient's access to medical records or information are applied to telemedicine consultation. The medical information of patients can be used for further treatment researches without the exposure of the identity.
4. Risks & Benefits
Patients had been given an opportunity to understand the risks and benefits of telemedicine consultation and their questions regarding telemedicine consultation had been answered. Complaints can be made through online channels or by calling the complaint line.
5. Patient Rights
Patients can withhold or withdraw their consent to the Telemedicine Consultation at any time and it is guaranteed by laws that any action will not affect further treatment.