Telemedicine Services Consent Agreement

Patient Information

Name: _______________________________ Date of Birth: ________________________ Membership ID: _______________________

Consent for Telemedicine Services

1. Nature of Telemedicine

I understand that telemedicine involves the use of electronic communications (video, audio, and other telecommunications) to enable healthcare providers to deliver medical services remotely.

2. Benefits & Risks

Benefits:

• Convenient access to medical care
• Reduced travel and waiting time
• Continuous care management

Potential Risks:

• Technical difficulties or disruptions
• Limited physical examination capabilities
• Potential privacy/security risks despite safeguards

3. Patient Responsibilities

I agree to:

• Provide accurate medical information
• Be in a private, quiet location during sessions
• Have proper technology and internet connection
• Inform the provider of my physical location during each session

4. Emergency Protocol

I understand that telemedicine is not suitable for medical emergencies. For emergencies, I will call 911 or go to the nearest emergency department.

5. Privacy & Security

I understand that:

• All existing confidentiality protections under HIPAA apply
• Electronic systems used will incorporate network and software security protocols
• No recordings of sessions will be made without separate written consent

6. Fees & Insurance

I understand that:

• Telemedicine services are included in my concierge membership
• Additional services may incur separate charges
• Insurance coverage varies by carrier and plan

Acknowledgment

I have read and understand the information provided above regarding telemedicine services.

Patient Signature: ______________________ Date: __________

Provider Signature: _____________________ Date: __________