Consent to Telehealth
Essential Telehealth (telemedicine) patient consent to telehealth. By submitting an order, you agree to the contents of the following document.
Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Protected Health Information (PHI) is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
The purpose of this form is to obtain your consent for a telehealth visit with one of our contracted healthcare Providers.
I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format.
I understand that I may opt out of the telehealth visit at any time. This will not change my ability to receive future care through Essential Telehealth’s contracted Providers.
I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Michigan at the time of this service.
I understand that telehealth billing information is collected in the same manner as a regular office visit and that Essential TeleHealth provides access to concierge medicine via contracted Providers and does not accept insurances.
I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:
- It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
- Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
- Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.
I agree that information exchanged during my telehealth visit will be reviewed and maintained by the contracted Providers, other ancillary staff, and any business associates involved in my care.
I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records).
I understand that Essential Telehealth and their contracted Providers have made every effort to provide a secure HIPAA-compliant method of video and audio communication.
I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.
I agree that Essential TeleHealth and its contracted Providers are not responsible for breaches of confidentiality caused by an independent third party or by me.
I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.
I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider.
I understand that electronic communication cannot be used for emergencies or time- sensitive matters.
I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations including, but not limited to further diagnostic testing, such as lab testing, a biopsy, an in-office visit, or emergency services.
I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).
I understand that Essential Telehealth and their contract Providers may choose to forward my information to an authorized third party. Therefore, I agree to inform the healthcare Provider of any information I do not wish to be transmitted through electronic communications.
By agreeing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.
I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided in-person or via telehealth.
To the extent permitted by law, I agree to waive and release Essential Telehealth, their contract Providers, and his or her affiliated practices, or ancillary staff from any claims I may have about the telehealth visit conducted today.
I understand that electronic communication should never be used for emergency communications or urgent care requests. If you believe you are suffering an emergency please immediately contact your local 911 services to seek immediate emergency medical care.
I understand that due to the state of the current national emergency crisis, and any other national emergencies, telehealth is offered by Essential Telehealth’s contracted physician Providers to appropriate patients in an effort to comply with federal and state mandates of isolation and social distancing as an effort to provide protection to everyone.
I certify that I have read and understand this agreement and I had the opportunity to have questions answered to my satisfaction.
I certify that if I’m being represented legally via a power of attorney, that my legal representative fully understands and agrees to the exact language in this agreement acknowledging the telehealth informed consent provided by Essential Telehealth.