Informed Consent for Telemedicine Services

Patient Name*
Date of Birth*
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.

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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.

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 access 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 during 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. If 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.

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Copy of Form*