Informed Consent for Telehealth Services - Rocky Mountain Infectious Disease Specialists

Informed Consent for Telemedicine Services
Patient Name*
First Last
Date of Birth*
Patient Location:*
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 As long as this consent is in force (has not been revoked) Rocky Mountain Infectious Diseases may provide health care service to me via telemedicine without the need for me to sign another consent form.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):*
Date*
MM slash DD slash YYYY
If authorized signer, relationship to patient:
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Witness
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*
First Last
Patient Signature*
Date*
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Time*

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AM/PM
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Witness
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Patient Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Height*
Weight (lbs.)*
Reason for Visit:*
Allergies (include reaction):
Medications/Dose:

Patient Health Questionnaire
Patient Name*
First Last
Date of Birth*
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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Informed Consent for Telemedicine Services

Informed Consent of Telehealth Evaluations

Social History

Family History

Patient Health Questionnaire