Consent For Telemedicine Services


Telemedicine is the delivery of healthcare services when the health care provider and the patient are not in same physical location through the use of technology. Providers may include primary care practitioners, specialist, and/or subspecialist . Electronically transmitted information maybe used for diagnosis, therapy, follow-up and/or patient education, and may include any of the following

  • Patient medical records.
  • Medical images.
  • Interactive audio, video, and/or data communication
  • Output data from medical devices and sound and video files

The interactive electronic systems used will incoperate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure it's integrity against intentional or unintentional corruption.

By Signing this form, I understand and agree to the following:

  • The laws that protect the privacy and confidentiality of medical information also implies to telemedicine. No information obtained during a telemedicine encounter which identifies me will be disclosed to reseachers or other entities without my consent
  • I have the right to withhold or withdraw the cosent to the use of telemedicine during the course of my care at any time. I understand that my withdrawl of consent will not affect any future care or treatment, nor will it subject me to risk the loss or withdrawl of any health benefits to which I am otherwise entitled.
  • I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
  • A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My physician has explained the alternative care methods to my satisfaction
  • Telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
  • I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse.

Patient Consent to the use of telemedicine

I have read and understood the information provided above regarding telemedicine, have discussed it with my physicians or such assistants as may be designated and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I herby consent to and authorize National TRT Clinics to use telemedicine in the ciurse of my diagnosis and treatment.

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