Modupe Aiyegbusi, MD - Publicforms

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Acute Visit Questionnaire Adult +18 CPE- Physical Forms Adult Health & History Form Adult Vaccine Questionnaire Ages 12-17 CPE - Physical forms Ages 5-8 CPE - Physical forms Ages 9-11 CPE Physical forms Child/Teen Vaccine Questionnaire Consent to use Telemedicine Covid-19 Screening Diabetes Form Flu Vaccine Questionnaire 21-22 Follow-Up Visit Questionnaire GAD 7- Generalized Anxiety Screening Medicare Wellness New Medicare Wellness New patient pediatric Health & History Form Ages 12-17 New patient pediatric Health & History Form Ages 5-8 New Patient Registration form all ages PHQ-9 - Patient Health Questionnaire Pre-Op/ Physical form Tuberculosis Risk Assesment Questionnaire

Consent to use Telemedicine

Consent to Use Telemedicine

Physician : Modupe Aiyegbusi, MD

Patient Name: *

Date of Birth *

I am physically located n California. At the beginning of each telemedicine session, I will help my doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed and whether I am in a situation conductive to private, uninterrupted communication. By signing this consent, I understand and agree:

1. My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when in located in any other state or country. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.

2. Nature of Telemedicine - Telemedicine involves the use of audio, video , or other electronic data communication to interact with you and deliver health care services, including assessment, depression treatment and evaluation. Potential Benefits: (which is not guaranteed or assured) includes: (a) Access to easier medical care. (b) Telemedicine has been found to be effective in treating a wide range of disorders, and are potential benefits. However, there is no guarantee that all treatment of all patients will be effective. (c) During Covid-19 pandemic; reduce exposure to patients, including staff and other individuals at a physical location. Potential risk including but not limited to inability to conduct a hands-on physical examination on you. Interruptions, care unauthorized access and technical difficulties. I understand some of these technological challenges including software, hardware and internet connections. Which may result in interruptions and loss of data. I understand that my provider is not responsible for any technological problems of which we have no control over. We do not guarantee that technology will be available or work as expected. I will not hold provider responsible for lost information

3. My doctor believes that telemedicine services are appropriate for my medical conditions and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.

4. If my doctor believes at any time that another form of services ( for example, a traditional in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule in person when available or refer me to a healthcare provider in my area who can provide such services.

5. I have the right to withdraw consent to the use of telemedicine services at any time and receive in person healthcare services.

6. I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology.

7.I agree to have the necessary computer, equipment and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications. I understand that it is my obligation to notify my provider of any other person in the location, even on or off camera and who can hear or see the session as confidential information may be discussed. It is your responsibility to ensure privacy at your location.

8. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination to researchers or other healthcare providers will not occur except as required by federal or California state law. I understand that I am responsible for information securing on my device, including but not limited to computer, tablet or phone and in my own location. Updox telemedicine services is the technology service we will use to conduct telemedicine My staff have discussed the use of this platform. Prior to each session, you will receive a text message link or e-mailed link to enter the waiting room until the session begins other means may be face-time is not hipaa compliant for the duration of the current covid pandemic and telephone Audio Only visit to maintain confidentially, I will not share my telemedicine appointment link or information with anyone not authorized to attend the session.

9. I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to "auto remember" usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increase s my risk of a privacy violation.

10. I agree for my pictures to be captured during the telemedicine services. I understand the resulting images will become part of my medical record.

11. I have the right to access my medical information and obtain copies of my medical records in accordance with California law.

12. I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.

I read and understand the information provided n this Consent to Use of Telemedicine, I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction. I understand and agree that I am signing this consent electronically and that I have reviewed, understood and accept the risks and benefits of telemedicine as described above and wish to receive such services. If I am signing on behalf of a minor, incapacitated or otherwise dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services and I accept financial responsibility for services rendered.

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