SUNIL LALLA, MD FCCP
TELEMEDICINE PATIENT CONSENT FORM
1.PURPOSE: The purpose of this form is to obtain your consent and understand that telemedicine is the use of electronic information and communication technologies by the 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 Sunil Lalla, MD PA providing health care services to me vital medicine.
2. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation:
a. Details of your medical history, examinations, x-rays, and test will be discussed with other health professionals through the use of interactive video, audio and telecommunication technology.
b. A non-medical technician may be present in the telemedicine studio to aid in the video transmission.
c. Video, audio and/or photo recordings may be taken of your during the procedure(s) or services (s).
3. MEDICIAL INFORMATION AND RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent.
4. CONFIDENTIALITY: I understand that there are risk from telemedicine, including but not limited to: loss of records from failure of electronic equipment: power failure with loss of communications; and invasion of electronic records from outside (hackers). In addition, signs and symptoms that might be detected during an in-person physical examination may not be detected through telemedicine. I understand that I have the option of seeing another physician on a face to face basis that could provide me with observations and recommendations. I warrant that
the provider observations/recommendations are limited to scope and nature to the specific issues discussed during the telemedicine consult.
5. RIGHTS: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entities.
6. DISPUTES: You agree that any dispute arriving from the telemedicine consult will be resolved in Florida and that Florida law shall apply to all disputes.
7. FINANCIAL: I understand that I will be responsible for any copayments or coinsurances that apply to my telemedicine visits.
8. RISKS, CONSEQUENCES AND BENEFITS: You have been advised of all the potential risks, consequences and benefits of telemedicine, including inadequate evaluation and diagnosis. Your health care practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered, and you understand the written information provided above.
I agree to participate in a Telemedicine consultation as described above.
Please print your name in the signature field. Typing your name will be counted as an electronic signature. I am the individual who has typed their name actually signed the document.