I understand that telemedicine is a means used for remote communication and exchange of information, particularly for delivering health care services via an electronic medium such as the internet with facilities for audio and video communication.

I understand the laws that protect the privacy and confidentiality of medical information applies likewise in telemedicine. However, through telemedicine, the health care provider cannot control the patient's environment. I understand that my insurance service provider will have access to my health records and therefore I give my consent to the release of information whenever requested by them. 

I understand my right to withhold or withdraw my consent from the health care service provider or my physician. I understand that should I withhold or withdraw will not affect my relationship with the health care service provider or the doctor and my right to future care or treatment.

I understand my responsibility in terms of the charges that I may incur for the medical services I use for my self, regardless of the insurance coverage.

I understand that State laws require me to be within the state of New York, and particularly in any of the following places in order for me to be treated through telemedicine:

• Hospitals and Hospice care
• Facilities for mental health care, including a psychiatric center, development center, institute, clinic, ward, institution or building
• Physician offices
• Schools and child daycare centers
• Adult care facility
• At home