Telemedicine Patients 4

AUTHORIZATION AND CONSENT TO PARTICIPATE
IN TELEMEDICINE CONSULTATION

1) Purpose: The purpose of this form is to obtain your consent to participate in a telemedicine consultation with Ashish Sahai, M.D.

2) Nature of Telemedicine Consultation: During the telemedicine consultation:
a) Details of your child’s medical history, examinations, x-rays, and tests will be discussed with other health professionals through the use of interactive video, audio and telecommunications technology.
b) Physical examination of you may take place.
c) Non-medical technical personnel may be present in the telemedicine studio to aid in video transmission.
d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.

3) Medical Information and Records: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws.

4) Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and Florida State law apply to information disclosed during this telemedicine consultation.

5) Risks, Consequences & Benefits: The telemedicine consultation will be similar to a routine medical office visit, except interactive video technology will allow you to communicate with a physician at a distance. At first you may find it difficult or uncomfortable to communicate using video images. The use of video technology to deliver healthcare and educational services is a new technology and may not be equivalent to direct patient to physician contact. Following the telemedicine consultation, your physician may recommend an in-office visit or a visit to a local Hospital for further evaluation.

6) Rights: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the option to consult with the specialist in person if you travel to his or her location.

7) Disputes: You agree that any dispute arriving from the telemedicine consult will be resolved in Florida, and that Florida law shall apply to all disputes.

8) Financial Agreement: Neurospine Institute LLC will bill insurance for telemedicine services when these services have been determined to be covered by an individual’s insurance plan. In the event that insurance does not cover telemedicine or when there is no insurance coverage, the individual wishes to pay out-of-pocket.


I have been advised of all the potential risks, consequences and benefits of telemedicine. I have had an opportunity to ask questions about this information and all of my questions have been answered.

I understand the written information provided above. I hereby give my informed consent to participate in the use of telemedicine services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.