Telehealth Informed Consent Form

Dr. Ruben C. Artsworth
Neurologist

484-393-3303

1847 Dane Street
Sprague, WA, 99032

I understand the benefits for engaging in a telehealth consultation where it reduces the time in waiting to see a doctor. I will be able to utilize my time and get easier access to healthcare without traveling for needing of medical assistance that can be resolved through consultation.I understand that the facility for telehealth service responsible for video conferencing is not a source of healthcare or medical advice.I understand that telehealth does not guarantee all treatments to be effective.I understand that it is my responsibility to ensure privacy and security of communication to wherever I am located and however I am utilizing the service. I shall notify my doctor every time I am engaging and using the telehealth service.It shall be my responsibility to ensure the control and management, including prohibition and restriction of use of any virtual assistant artificial intelligence (AI) such as Alexa or risk its use. But in no case that I shall inform my doctor whether these are being utilized or enabled during session.I understand that any recording of telehealth sessions shall require consent with the doctor or specialist.I understand that the doctor is not responsible for any technological difficulties that may arise and he or she has no control over such matter.I understand that it is my responsibility to secure my device. Any breach or problem that may arise through my device such as computer, tablet, or mobile phone shall be borne by me, including, but not limited to sharing my link to a telehealth appointmentI understand that there is no perfect security and transmission of information in any remote communication and potential risks are inevitable and which may arise during telehealth sessions, such as but not limited to, interruptions, communication breach, or any other technical difficulties.I understand that I, my guardian, or my doctor can discontinue my telehealth consultation for grounds which may not appear to be beneficial to me or whether it is deemed by the one calling for discontinuation reasonable.Upon discussion with my doctor, it was explained to me the other possible treatments available.I understand that the telehealth service is not an emergency service. In case of emergency, I shall contact 9-1-1 or any other emergency service provided by the government or any institution.I understand that it is the duty of my doctor to notify an emergency personnel in the event that my, or other people's safety is at risk.I understand that telehealth service is a paid service. It shall be my obligation to contact my insurer to know whether or not the telehealth service is covered by my insurance or HMO. Otherwise, I shall solely be responsible for payment for the services.

By signing this form, I declare that I have had the opportunity to ask questions regarding the services that are available and within the scope of telehealth, and the questions were answered to my satisfaction. In this regard, I hereby give my informed consent to the use of telehealth

I declare that I am of legal age and I hereby give my voluntary consent to this informed consentThe patient is below legal age and a guardian shall give consent on behalf of the child

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Name of Guardian

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