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*6 New Patients: Telehealth (VideoChat)Consent form

Video Chat

Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose to improve patient care. Providers may include primary care practitioners, specialists, and/or sub specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

- Patient medical records - Medical images - Live two-way audio and video - Output data from medical devices and sound and video files.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.



Improved access to medical care by enabling a patient to remain in his/her home while the primary care provider obtains test results and consults in the outpatient clinic

More efficient medical evaluation and management,

Obtaining expertise of a distant specialist.



As with any medical procedure, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to:

In rare cases, information transmitted may not be adequate (e.g. poor resolution of images) to allow for appropriate medical decision making by the primary care provider.

Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.

In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.


Patient Consent To The Use of Telehealth

I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth, and that no information obtained in the use of Telehealth which identifies me will be disclosed to researchers or other entities without my consent. I have the right to withhold or withdraw my consent to the use of Telehealth during my care at any time, without affecting my right to future care or treatment. I have the right to inspect all information obtained and recorded during a Telehealth interaction and may receive copies of this information for a reasonable fee. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My primary care provider has explained the alternatives to my satisfaction. I understand that it is my duty to inform my primary care provider of electronic interactions regarding my care that I may have with other healthcare providers. I understand that I may expect the anticipated benefits from the use of Telehealth in my care, but that no results can be guaranteed or assured.

By checking this box I acknowledge I have read and understood the information provided above regarding Telehealth, have discussed it with my primary care provider or, and all my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telehealth in my medical care with HOME TOWNE FAMILY MEDICINE for my diagnosis and treatment.
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