Telemedicine Informed Consent to Treatment

Introduction

Care Live telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. Thus, telemedicine allows the provider to see and communicate with the patient in real-time.

Consent for Treatment

I voluntarily request Care Live physician(s) and other medical staff to participate in my medical care using telemedicine.

I understand that Care Live physicians:

• may practice in a different location than where I present for medical care,
• may not have the opportunity to perform an in-person physical examination, and
• rely on information provided by me.

I acknowledge that Care Live physicians’ advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions.

I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as a result or cure.

If Care Live physicians determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event that telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary.

If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert the Care Live physician and, in the case of emergencies dial 911, or go to the nearest hospital emergency department.

I understand that the disclosure of my medical information to Care Live physicians and medical staff, including the audio and/or video, will be by electronic transmission. Precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering.

I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.

10/3/18 Last Updated