Please read and review the following and sign below to indicate your understanding of and agreement with the below policies:
I understand that telemedicine is different from traditional medicine in that sessions will occur remotely via a HIPAA-compliant video teleconference (VTC) platform. I am familiar with the technology required for conducting telemedicine sessions and I will conduct all telemedicine sessions from a private, well-lit location.
I understand that some benefits of telemedicine include increased access to medical care and my personal convenience. I understand that some of the risks include (a) failure of VTC technology such that appropriate medical decision-making becomes impossible, (b) breach of confidentiality due to encryption failure or legal or illegal investigation, (c) a lack of access to all the information that might be available in a face-to-face visit, which could result in the omission of care involving other health problems or possible adverse drug interactions.
I understand that there may be technical limitations associated with receiving treatment via telemedicine; equipment may fail and my physician may determine at any time that the quality of the connection is not sufficient to continue. I will provide a backup telephone number to use in case of VTC failure.
I understand that the laws that apply to the practice of medicine and to the privacy of health care information also apply to telemedicine.
I understand that my physician will determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter.
I will notify my physician of my location prior to and at the onset of each telemedicine session. I will notify my physician if any other person can hear or see any part of any telemedicine session. It is my responsibility to ensure that my VTC equipment and software are operating properly prior to my appointment.
I understand that as a prerequisite for receiving treatment by VTC, I may be required to visit with my primary care provider (and to provide corresponding records) as directed, and/or to obtain laboratory testing.
I understand that even if I am accessing my physician from my own home, my physician may contact police or 911 in the event of life-threatening emergency.
I will not record any VTC session without my physician’s written permission and I understand that my physician will not record any session without my written permission.
My questions have been answered to my satisfaction. I understand my alternatives to treatment via telemedicine, which may include traditional outpatient appointments. I understand the risks and benefits of receiving treatment via telemedicine, and I hereby give my informed consent for the use of telemedicine in my medical care and authorize my physician to use telemedicine in the course of my diagnosis and treatment. I agree to hold Inspire Youth Psychiatry and Wellness PLLC and its physicians harmless from injuries or omissions that may be related to the malfunction or technical failure of equipment or system encryption.