Texas Telemedicine Consent Form

Texas Telemedicine Consent Form
Texas ABC Health - 698 Medical Lane, San Antonio, Texas, 78231
Name of Patient
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
Date
Email
example@example.com
Phone Number
Area CodePhone Number
Mobile Number
Area CodePhone Number
Texas laws define telemedicine as remote medical services provided to a patient by a physician who is licensed in Texas. With this, it should be noted that in order for the proper conduct of telemedicine, the physician must be within the vicinity of the state of Texas. This however requires that in the practice, the patient should also be within the state of Texas for the proper conduct of the service.
In order for the service of telemedicine to take place, please go through and understand each item in this informed consent form. If you have questions, please do not hesitate to let us know and we will be more than happy to answer them for you.
Consent
I voluntarily give my consent to engaging in telemedicine with the physician(s) for the purpose of treatment and diagnosis.I understand that telemedicine involves the use of audio, video, and/or data communication for consultation, diagnosis, treatment, or education purposes.I understand that telemedicine has its limitations and shall not be equal to a face-to-face consultation as the doctor cannot use the senses of touch or smell which may be needed during consultation and diagnosis, and that there is no assurance guaranteed to the benefits of telemedicine.I understand that with telemedicine, communication interruptions may arise which may not be the fault of the doctor nor mine. I understand that this instance may cause delay or problems in communication that may prevent proper engagement.I understand that I have the right to withhold or withdraw my consent from this telemedicine agreement and that such will not affect my right to further future care or treatment that of which I am entitled.I understand the laws in place that protect my privacy and that such privacy and confidentiality, particularly relating to health, such as that of HIPAA, likewise apply in telemedicine. Any dissemination of information that may personally identify my person shall require my prior written consent.I understand that these confidentiality rights is not absolute. Any matter that may involve abuse, harm, or violence towards a child, an elder, or any person shall permit the doctor to report to proper authorities if he or she do so believe the possibility of such event to happen or may have happened.
By signing and submitting this form I hereby declare that I have read and I fully understand all the information provided above. This information was discussed with me by my doctor or his or her representative, and all questions I have raised were answered to me to my full satisfaction. That I am located or living in the state of Texas and during my telemedicine visits, will be within the state of Texas
Representative
I am represented by an agent who shall sign this informed consent on my behalf
Name of Representative
First NameLast Name
Relation to Patient
Date Signed
MonthDayYear
Date
Signature
Clear
Name of Witness
First NameLast Name
Date Signed
MonthDayYear
Date
Signature
Clear
Should be Empty: