Pondworks Informed Consent to Telemedicine Consultation
I have been asked by my Pondworks provider to take part in a telemedicine consultation. I understand the following:
The purpose of the consultation is to assess and treat my medical/mental health condition.
The telemedicine consult is done through a secure, HIPAA-compliant, two-way video link-up, whereby my provider can see my image on the screen and hear my voice. However, unlike a traditional medical consult, the physician, nurse practitioner and/or therapist does not have the use of other senses that provide information. Thus, the visit may not be equal to a face-to-face visit.
Benefits and Risks: I understand that there are potential benefits and risks with the use of this new technology, These include but are not limited to:
Benefit: I may not need to travel to the Pondworks office.
Benefit: This technology provides access to my mental health care, including a limited physical examination.
Risk: The video connection may not work or may stop working during the consultation.
Risk The video picture or information transmitted may not be clear enough to be useful for the consultation.
Risk: I may be required to go to the Pondworks office if the information obtained via telemedicine is not sufficient to make a diagnosis and/or recommendation.
Risk: Although the telemedicine technology systems incorporate network and software security protocols, as well as Pondworks? physical, technical and administrative safeguards intended to protect my confidential patient information, there is a risk that my medical information could be interrupted, accessed or intercepted by an unauthorized person.
Acknowledgements:
I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. My provider cannot be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me. A lack of access to my complete medical record may result in adverse drug interactions, allergic reactions or other judgment errors.
I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.
I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
I can ask questions and seek clarification of the procedures and telemedicine technology.
In the event the telemedicine session is interrupted, due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary.
I can ask that the telemedicine exam and/or videoconference be stopped at any time.
I understand that Pondworks' providers are only licensed to provide telemedicine to patients who are physically in the state of Texas. If I travel out of state, I understand that I will need to reschedule my appointment.
If I need to reach my provider between appointments, I agree to leave a confidential voice mail for my provider at (512) 371-9555, Option 3.
If I have am having an emergency, I agree to follow the instructions provided at (512) 371-9555, Option 2.
I understand that I can make a complaint about my provider to the Texas Medical Board (http://www.tmb.state.tx.us/page/place-a-complaint, 800-201-9353) or the Texas Board of Nursing (https://www.bon.texas.gov/discipline_and_complaints_policies_and_guidelines_filecomplaint.asp, 512-305-6838).
Agreement: I have been given the opportunity to review this informed consent in full and given the opportunity to ask questions. I hereby give my informed consent for the use of telemedicine in my medical care.