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telemedicine
Telemedicine Concent
Purpose
The purpose of this form is to obtain your consent for a telemedicine consultation with Dr. J. Patrick Johnson. The purpose of this consultation is to assist in the diagnosis or treatment of:
Purpose
The purpose of this form is to obtain your consent for a telemedicine consultation with Dr. J. Patrick Johnson. The purpose of this consultation is to assist in the diagnosis or treatment of:
Enter Purpose
*
NATURE OF TELEMEDICINE CONSULTATION
Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal health information may be discussed with other health professionals with interactive video, audio and telecommunications technology. Additionally, a physical examination of you will take place and video, imaging, and/or audio recordings may be taken.
NATURE OF TELEMEDICINE CONSULTATION
Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal health information may be discussed with other health professionals with interactive video, audio and telecommunications technology. Additionally, a physical examination of you will take place and video, imaging, and/or audio recordings may be taken.
RISKS, BENEFITS AND ALTERNATIVES
The benefits of telemedicine include having access to medical specialists, additional medical information, and education without having to travel outside of your home. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to a telemedicine consultation is an in office, face-to-face visit with Dr. J. Patrick Johnson.
RISKS, BENEFITS AND ALTERNATIVES
The benefits of telemedicine include having access to medical specialists, additional medical information, and education without having to travel outside of your home. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to a telemedicine consultation is an in office, face-to-face visit with Dr. J. Patrick Johnson.
STAFF
Additionally, non-medical technical personnel may participate in the telemedicine consultation to aid in the audio/video link with Dr. J. Patrick Johnson.
STAFF
Additionally, non-medical technical personnel may participate in the telemedicine consultation to aid in the audio/video link with Dr. J. Patrick Johnson.
MEDICAL INFORMATION AND RECORDS
All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.
MEDICAL INFORMATION AND RECORDS
All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.
CONFIDENTIALITY
All existing confidentiality protections under federal and California law apply to information used or disclosed during your telemedicine consultation.
CONFIDENTIALITY
All existing confidentiality protections under federal and California law apply to information used or disclosed during your telemedicine consultation.
RIGHTS
You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care, treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.<br><br> Dr. J. Patrick Johnson has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all my questions have been answered. I have read and agreed to a Telemedicine consultation.
RIGHTS
You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care, treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Dr. J. Patrick Johnson has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all my questions have been answered. I have read and agreed to a Telemedicine consultation.
Enter Date
*
Full Name
*
Your Signature
You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care, treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.<br><br> Dr. J. Patrick Johnson has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all my questions have been answered. I have read and agreed to a Telemedicine consultation.
Your Signature
You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care, treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
Dr. J. Patrick Johnson has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all my questions have been answered. I have read and agreed to a Telemedicine consultation.
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