CASPER, WYOMING
1450 East A Street, Casper, WY 82601
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(307) 234-8700
serving Wyoming and nearby areas
Informed Consent for Telehealth Services
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Informed Consent for Telemedicine Services
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Patient Location:
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I understand that 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 the providers of Rocky Mountain Infectious Diseases providing health care services to me via telemedicine.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have acces to your medical records for quality review/audit.
I understand that I will be responsible for any copayment or coinsurances that apply to my telemedicine visit.
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 ability to receive future care or treatment. I may revoke my consent orally or in writing at any time by contacting Rocky Mountain Infectious Diseases at (307) 234-8700. As long as this consent is in force (has not been revoked) Rocky Mountain Infectious Diseases may provide health care service to me via telemedicine without the need for me to sign another consent form.
Signature of Patient (or person authorized to sign for patient):
*
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Date
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MM slash DD slash YYYY
If authorized signer, relationship to patient:
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Copy of Form
*
Yes, please send me a copy of this consent form.
No, I do not need a copy of this consent form.
Informed Consent of Telehealth Evaluations
For convenience and cost-efficiency, some infectious diseases services are available by two-way interactive video communication and/or by the electronic transmission of information. Referred to as “telemedicine” or “telehealth,” this means that you may be evaluated and treated by a health care provider or specialist from a different location. Since this is different than the type of evaluation with which you are familiar,
you must certify that you understand and agree to the following:
1. The evaluating health care provider or specialist will be at a different location from me. A medical professional (MP) will be at my location to assist me with the evaluation.
2. The medical professional may transmit or share electronically details of my medical history, examinations, x-rays, test, photographs or other images with the provider who is at a different location.
3. Details of my medial history, examinations, medications, x-rays, and tests will be discussed with the provider who is at a different location.
4. I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, the provider and the medical professional. I will give my verbal permission prior to additional personnel being present.
5. Video recordings may be taken of the telehealth evaluation, after I have given my written permission prior to recording.
6. The medical professional for whom the on-site examination or treatment is performed will keep a record of the evaluation in my medical record. The evaluating provider shall also keep a record of the evaluation
Noting all of the above, I understand that my participation in the process described (called telemedicine or telehealth) is voluntary.
RELEASE OF INFORMATION:
All existing laws regarding access to your medical information and copies of your medical records, including the Health Insurance Portability and Accountability Act (HIPAA) and apply to this telehealth evaluation. Additionally, dissemination of any patient-identifiable images or information from this telehealth interaction to researchers or other entities shall not occur without your consent.
I further understand that I have the right to:
1. Refuse the telehealth evaluation, or stop participation in the telehealth evaluation at any time.
2. Limit any physical examination proposed during the telehealth evaluation.
3. Request that the nurse refrain from transmitting my information if I make the request before the information is transmitted.
4. Request that nonmedical personnel leave the room(s) at any time.
5. Request that all personnel leave the room(s) to allow a private evaluation with the off-site provider.
I acknowledge that the health care providers involved have explained the evaluations in a satisfactory manner and that all questions that I have asked about the evaluation have been answered in a manner satisfactory to me or to my representative. Understanding the above, I consent to the telehealth process described above.
Patient Name
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First
Last
Patient Signature
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Date
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Time
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Hour
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AM/PM
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Patient Name
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Phone
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Email
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Address
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Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
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Height
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Weight (lbs.)
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Reason for Visit:
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Allergies (include reaction):
Medications/Dose:
Medical History:
Check all that apply.
ADD/ADHD
Liver Disease
Neuropathy
Seizures
Thyroid Disease
Psychosis
PTSD
Borderline Personality
Depression
Fatigue
Anxiety
Bipolar Disorder
OCD
ODD
Other (detail below in comments)
Medical History Comments/Details:
Surgical History:
Check all that apply.
Appendectomy
Brain Surgery
Breast Surgery
C-Section
CABG
Cholecystectomy
Colon Surgery
Cosmetic Surgery
Eye Surgery
Fracture Surgery
Hernia Repair
Hysterectomy
Joint Replacement
Amputation
Prostate Surgery
Intestinal Surgery
Spine Surgery
Tubal Ligation
Valve Replacement
Vasectomy
Other (detail below in comments)
Surgical History Comments/Details:
Social History
Alcohol Use
*
Yes
No
How many drinks per week?
Nicotine Use
*
Current
Former
Never
Sexually Active
*
Yes
No
Partners
Check all that apply.
Male
Female
Birth Control
Yes
No
Exercise
*
Yes
No
How often per week?
Do you feel safe at home?
*
Yes
No
Unexplained weight loss in the last 3 months?
*
Yes
No
How much?
Do you have an advanced directive?
*
Yes
No
Have you had recent thoughts of taking your own life?
*
Yes
No
Have you had thoughts of harming yourself or others?
*
Yes
No
Drug Use
*
Yes
No
Past Use
Type
Amphetamines
Codeine
Hydrocodone
Mescaline
Opium
Fentanyl
Hydromorphone
Ketamine
PCP
LSD
Methamphetamines
Oxycodone
Anabolic Steroids
Barbiturates
Marijuana
Hashish
Morphine
Inhalants
Cocaine/”crack”
Heroin
Other (detail below in comments)
Drug Use Comments/Details:
Family History
Adopted
*
Yes
No
Known Family History
*
Yes
No
Tell us about your Mother.
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about your Father
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Do you have siblings?
Yes
No
How many?
Tell us about Sibling 1.
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about Sibling 2.
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about Sibling 3.
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about Sibling 4.
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about your Maternal Uncle
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about your Paternal Uncle
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about your Maternal Grandfather
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about your Maternal Grandmother
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about your Paternal Grandfother
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Tell us about your Paternal Grandmother
Check all that apply.
Alive
Deceased
ADD/ADHD
Alcohol Abuse
Anxiety
Bipolar
Dementia
Depression
Drug Abuse
OCD
Paranoid
Physical Abuse
Schizophrenia
Seizures
Sexual Abuse
None
Patient Health Questionnaire
Patient Name
*
First
Last
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
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29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date
*
MM slash DD slash YYYY
Over the last 2 weeks, how often have you experiences any of the following problems?
*
Not at all
Several days
More than half the days
Nearly Everyday
Everyday
Had little interest or pleasure in doing things?
Felt down, depressed or hopeless?
Had trouble falling/staying asleep, sleeping too much?
Felt tired or had little energy?
Had poor appetite or overate?
Felt bad about yourself, or that you are a failure or had let yourself or your family down?
Had trouble concentrating on things, such as reading the newspaper or watching TV?
Moving or speaking so slowly that other people could have noticed? Or the opposite, been so fidgety or restless that you have been moving around a lot more than usual?
Thoughts that you would be better off dead or of hurting yourself in some way?
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Is there anything else you would like us to know?
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