Telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider, and hereby consent to Al Arif Hospital providing health care services to me via telemedicine for improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up, and/or education and may include
I understand there are potential risks with this technology:
I understand that my health care provider wishes me to engage in a telemedicine consultation.
I understand that the telemedicine visit will be done through a two-way video link-up. The healthcare provider will be able to see my image on the screen and hear my voice. I will be able to hear and see the healthcare provider.
I understand that a limited physical examination will take place during telemedicine and it cannot replace a full medical examination done physically at the medical center.
I authorize the details of medical history/examination to be discussed with other health care professionals who may need this information for continuing care purposes.
I also understand other individuals may be present to operate the telecommunication technology and that they will take reasonable steps to maintain the confidentiality of the information obtained.
I understand that my healthcare provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine that identifies me will be disclosed to researchers or other entities without my consent.
I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
I certify that this online consultation form has been fully explained to me. I have read, understood, and agreed with its contents. I understand all the potential risks, consequences, and benefits of telemedicine. I volunteer to participate in the telemedicine examination. I authorize the health care providers involved to perform procedures that may be necessary for my current medical condition.
I hereby give my informed consent for the use of telemedicine in my medical care.