Telehealth consent
SY NP IN FAMILY HEAL TH PLLC
Telehealth is the delivery of healthcare services when the healthcare provider and the patient (the “Patient”) are not in the same physical location and communicate through technology. Electronically transmitted information may be used for diagnosis, treatment, follow-up, prescribing, or education and may include medical records, medical images, interactive audio, video and/or data communications, and output data from medical devices, sound and video files.
The Patient is hereby advised that the care provided by practitioners through SY NP IN FAMILY HEAL TH PLLC (the “Practice”) is not a replacement for an in-person relationship with a primary care provider. If the Patient does not have a primary care practitioner, they are advised to seek the care of one.
The Patient understands the following with respect to telehealth offered by the Practice:
The Patient has elected to have a telehealth visit instead of an in-office visit at the Practice. The Patient agrees that the Practice will determine whether the Patient’s condition is appropriate for telehealth and acknowledges that the Practice may recommend an in-person visit in lieu of, or in addition to, the telehealth visit.
The Patient has had an opportunity to review the Practice’s providers’ credentials and has selected his or her preference for a provider.
There are potential risks associated with the use of telehealth, including, but not limited to: the information transmitted may be less comprehensive than that available during an in-person visit and may therefore result in decreased accuracy of diagnosis or medical decision-making; delays in medical evaluation or treatment could occur due to deficiencies or failures of the telehealth equipment; security protocols could fail, causing a breach of privacy.
The Patient understands that telehealth often involves electronic transmission of the Patient’s protected health information (“PHI”). The Patient’s PHI includes, but is not limited to, the Patient’s individually identifiable health information; medical history; diagnoses; communications to and from the Patient’s other health care provider(s); etc. The Patient understands that PHI may be lost due to technical failures, cyber intrusion or other issues disrupting the Patient’s telehealth visit or causing delays in response from the Practice. The Patient assumes these risks and holds the Practice and its providers harmless from any claims arising out of the use of telehealth to conduct the visit. The Patient understands that PHI obtained during the telehealth visit will not be disclosed to others without the Patient’s consent unless permitted by applicable law and in accordance with the Practice’s Notice of Privacy Practices.
The Patient has the right to request that we submit information about his or her treatment with the Practice to his or her primary care physician. If the Patient makes such a request and consents to the disclosure of PHI, the Practice will send the Patient’s medical record, and/or a report containing an explanation of the Patient’s treatment, to the Patient’s primary care physician within 72 hours of his or her consultation with the Practice.
The Patient acknowledges and understands that the telehealth visit is not intended to support or carry emergency calls to Practice. In the event of a clinical emergency, dial 911 immediately. You acknowledge and agree that: (i) by utilizing the telehealth service the provider encounter is not a replacement for your existing relationship with your primary physician or other primary healthcare provider; (ii) you will contact your primary physician or other primary healthcare provider immediately should your condition change or any symptoms worsen; and (iii) if you require emergency care, you will contact your local emergency services immediately.
The Patient has the right to withhold or withdraw consent for telehealth at any time without affecting the Patient’s right to future care, treatment, benefits, or programs for which he or she is otherwise entitled. The Patient understands that if others are present at Patient’s location during the Patient’s telehealth visit, the confidentiality of the Patient’s telehealth visit may be compromised.
The Patient understands the alternatives to telehealth, such as an in-person encounter, as they have been explained, and in choosing to participate in a telehealth visit understands that some parts of the exam may require in-person physical testing to be performed at the direction of the Practice providers.
THE PATIENT UNDERSTANDS THE PATIENT WILL BE RESPONSIBLE FOR PAYMENT. THE PRACTICE DOES NOT ACCEPT INSURANCE. ALL OUT-OF-POCKET EXPENSES ASSOCIATED WITH THE TELEHEALTH VISIT ARE DUE PRIOR TO THE TELEHEALTH VISIT.
The Patient understands and agrees that he or she must be physically located in the state that corresponds to the state listed in their registration at the time of any telehealth consultation. The Patient represents and warrants that he or she will be physically located in such state for the full duration of each telehealth visit. The Patient further acknowledges that if he or she is not physically located in the registered state at the time of a scheduled telehealth visit, the Practice may decline to provide treatment via telehealth.
The Patient understands that the Practice’s healthcare professionals may exercise their professional judgment to prescribe medication or other treatment to the Patient specifically to treat the Patient’s diagnosed condition, but there is no guarantee that the Patient will be prescribed a medication or other treatment. If a medication or other treatment is ordered, the Patient, at all times, has the ability to request that his or her medication or treatment be fulfilled at the ancillary provider (e.g., pharmacy) of the Patient’s choice.
The Patient has been advised of all the potential risks, consequences and benefits of telehealth, including risks related to the security of electronic communications. The Patient has been afforded the opportunity to ask questions about the information presented within this Telehealth Consent document. All the Patient’s questions have been answered, and he or she understands the information contained herein.
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By entering my name below, I acknowledge that I have read and understand the terms of this Telehealth Consent, and I agree to receive services from the Practice via telehealth. I represent and warrant that I am authorized to provide this consent.
I can contact the Practice at 718-814-9863 for a copy of this Telehealth Consent or to withdraw my consent as applicable.
