TELEMEDICINE CONSENT FORM

Telemedicine is the delivery of health care services using interactive audio and/or video technology, where the patient and Provider are not in the same physical location. During your telemedicine consultation with a Provider, details of your medical or health history and personal health information may be discussed using interactive audio, video, and/or other telecommunications technology, and the Provider may perform a physical exam through these technologies. Depending on your medical or health history and/or specific complaint, you may be asked to provide information through other electronic means and verify your identity with a driver’s license or other legal document. The telemedicine services you receive from Emed Multispecialty Group are not intended to replace a primary care physician relationship, be your permanent medical home, or be used during a medical emergency. If you think you are having a medical emergency, you should dial 911 immediately. You should seek emergency help or follow-up care when recommended by a provider, symptoms worsen, or when otherwise needed, and continue to consult with your primary care physician and other health care professionals as recommended. We may make arrangements for follow-up care either through Emed Multispecialty Group, your primary care provider, or other health care providers. If the transmission fails during your telemedicine consultation with a provider, then every attempt will be made to contact you to help you get reconnected. You will have direct access to Healow and Emed Multispecialty Group services to follow-up on medication reactions, side effects, or other adverse events. Among the benefits of Emed Multispecialty Group via Healow is improved access to health care professionals and convenience. However, there are potentials risks associated with the use of telemedicine. These risks include, but are not limited to: 1. In some instances, the information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.) 2. Delays in evaluation or treatment could occur due to failure of the electronic equipment; 3. In some instances, a lack of access to all of your medical records could result in adverse drug reactions or allergic reactions or other judgment errors; 4. Although the electronic systems we use will incorporate networks and software security protocols to protect the privacy and security of health information, in some instances, security protocols may fail and cause a breach of privacy and/or personal health information. I, (Patient Name) have read the information, or have had it read to me, and have received a copy of this agreement. I understand my responsibilities and agree to the above conditions while receiving opioid medication.
    Telemedicine is the delivery of health care services using interactive audio and/or video technology, where the patient and Provider are not in the same physical location. During your telemedicine consultation with a Provider, details of your medical or health history and personal health information may be discussed using interactive audio, video, and/or other telecommunications technology, and the Provider may perform a physical exam through these technologies. Depending on your medical or health history and/or specific complaint, you may be asked to provide information through other electronic means and verify your identity with a driver’s license or other legal document. The telemedicine services you receive from Emed Multispecialty Group are not intended to replace a primary care physician relationship, be your permanent medical home, or be used during a medical emergency. If you think you are having a medical emergency, you should dial 911 immediately. You should seek emergency help or follow-up care when recommended by a provider, symptoms worsen, or when otherwise needed, and continue to consult with your primary care physician and other health care professionals as recommended. We may make arrangements for follow-up care either through Emed Multispecialty Group, your primary care provider, or other health care providers. If the transmission fails during your telemedicine consultation with a provider, then every attempt will be made to contact you to help you get reconnected. You will have direct access to Healow and Emed Multispecialty Group services to follow-up on medication reactions, side effects, or other adverse events. Among the benefits of Emed Multispecialty Group via Healow is improved access to health care professionals and convenience. However, there are potentials risks associated with the use of telemedicine. These risks include, but are not limited to: 1. In some instances, the information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.) 2. Delays in evaluation or treatment could occur due to failure of the electronic equipment; 3. In some instances, a lack of access to all of your medical records could result in adverse drug reactions or allergic reactions or other judgment errors; 4. Although the electronic systems we use will incorporate networks and software security protocols to protect the privacy and security of health information, in some instances, security protocols may fail and cause a breach of privacy and/or personal health information. I, (Patient Name) have read the information, or have had it read to me, and have received a copy of this agreement. I understand my responsibilities and agree to the above conditions while receiving opioid medication.
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