Consent to Participate in Telemedicine Consultation

 Purpose: This form is intended to obtain your permission to participate in a telemedicine consultation. 

Introduction: Telemedicine is the use of video conferencing to enable healthcare providers at a different location to provide health care treatment to you and/or consult with you and your health care provider about your health care options and decisions. Telemedicine consultations are not the same as direct patient/healthcare provider visits, as you will not be in the same location as the consulting provider.  Telemedicine allows Vermillion-Parke Community Health Center to provide services to you that may otherwise require you to travel long distances.  Your participating in any telemedicine consultation is completely voluntary. 

Process: By signing this form, you are acknowledging that you understand the following:

·       Details of your medical history, including but not limited to, images, x-rays and tests may be shared electronically and discussed with the consulting provider.

·       A physical examination may take place.

·       Non-medical personnel may be present to assist in operating video conferencing equipment.  You will be informed of any non-medical personnel present during the video-conference. 

·       Video, audio, and/or photo recordings may be taken during the procedure to aid in documenting the progress of your treatment. 

·       The responsibility of the consulting provider regarding your health care will terminate upon conclusion of the teleconference. 

·       Your provider as well as the consulting provider may keep a record of the consultation.

Possible Risks: By signing this form, you are acknowledging that you understand the following:

·       Despite our best efforts to protect the privacy of patient information, security protocol could fail causing a breach of privacy of personal medical information.

·       Information provided by telemedicine to the consulting provider may be insufficient to allow for treatment and general medical care decision to be made. 

·       Delays in medical evaluation and treatment may occur due to failures of the electronic equipment.

Consent: By signing this form, you are consenting to participate in a telemedicine consultation.  You are acknowledging that you have read and understand the provisions in this form.  If you are unable to read, you are acknowledging that your health care provider has read this form to you.  You are acknowledging that your health care provider has explained to you how telemedicine video conferencing works.

I hereby consent to participation in a telemedicine consultation.