Telehealth Informed Consent for Gastroenterology Services

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Date: _____________________

Nature of Telehealth Services

I understand that telehealth involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location.

Understanding and Agreements

1. Nature of Virtual Consultation

   • I understand that my gastroenterology provider will be at a different location from me
   • My healthcare provider will assess my condition using interactive video, audio, and telecommunications technology
   • A physical examination may be performed remotely

2. Benefits & Limitations

   • Improved access to gastroenterological care
   • More efficient medical evaluation and management
   • I understand that a telehealth consultation may have limitations compared to an in-person visit

3. Medical Information & Records

   • All existing laws regarding medical records access and confidentiality apply to telehealth
   • All medical information transmitted during the telemedicine consultation is part of my medical record

4. Technology Risks & Alternatives

   • Potential technical difficulties or interruptions
   • Possible security breaches despite best encryption efforts
   • Right to discontinue telehealth services and request in-person care

5. Emergency Situations

   • Telehealth is not intended for emergency situations
   • In case of an emergency, I will call 911 or go to the nearest emergency room

Patient Acknowledgment

I have read and understand the information provided above regarding telehealth. I hereby give my informed consent for the use of telehealth in my gastroenterological care.

Patient Signature: _________________ Date: _________________

Provider Signature: ________________ Date: _________________