Telemedicine Informed Consent Form California

Telemedicine Informed Consent Form California
Angelica Lewis, MD
Neurologist
3154 Doctors Drive
Los Angeles, CA, 90017
310-341-3615
drlewis@sampleemail.com
This form intends to acquire the consent of the patient to engage with the physician named above on telemedicine.
The physician will provide orientation and with regard to the items and by which the patient shall mark each checkbox below, sign this form, and submit as confirmation for the consent for this telemedicine engagement.
Please check as you understand each item in this consent form*
I understand that telemedicine is the use by a health care provider of communication technologies available such as the internet for delivery of health care services via audio and video regardless to the location of the parties in communication.I understand the benefits with the use of telemedicine, as well as its limitations whereas there can be no guarantee to the results of all treatments made through this medium.I understand the limitations with the use of telemedicine where it cannot be fully equal to face-to-face mode of treatment and such delays may incur due to possible cases of intermittent communication that may arise and which the telemedicine service provider is of no fault.I understand that there are state laws that help protect my privacy by standardizing confidentiality and information security that apply to telehealth and telemedicine consultations such as HIPAA. However, in case my insurance need access to my medical information, I hereby grant release of information requested to my insurance provider and/or its representatives.I understand that my participation is voluntary and I have the right to withhold, or withdraw my consent to the use of the telemedicine anytime. I understand that my withdrawal does not affect any future treatment with the provider.I am aware and shall solely be responsible for any charges incurred with the use of telemedicine and shall inform the telemedicine service provider the mode of payment I shall prefer.I understand that I this telemedicine informed consent form has sole jurisdiction in the state of California and therefore I must be a resident in California to be treated through telemedicine.
By signing this form, I affirm my voluntary consent to this telemedicine engagement. I understand that each item above was explained to me. I was given the opportunity to ask my questions and the questions were answered accordingly and to my satisfaction.
Representative
A representative shall sign this informed consent on behalf of the patient with authorization granted by the patient.
Name of Patient
First NameLast Name
Email of Patient
example@example.com
Phone Number of Patient
Area CodePhone Number
Mobile Number of Patient
Area CodePhone Number
Signature of Patient
Clear
Date Signed
MonthDayYear
Date
Representative
First NameLast Name
Email of Representative
example@example.com
Phone Number of Representative
Area CodePhone Number
Mobile Number of Representative
Area CodePhone Number
Date Signed
MonthDayYear
Date
Signature of Representative
Clear
Should be Empty: