TELEMEDICINE CONSENT HAMILTON HEALTH & WELLNESS, LLC / PROVIDER

Telemedicine is the delivery of healthcare services when the healthcare provider and the patient (the “Patient”) are not in the same physical location and communicate through technology. Electronically transmitted information may be used for diagnosis, treatment, follow-up, prescribing, or education and may include medical records, medical images, interactive audio, video and/or data communications, and output data from medical devices, sound, and video files.

The Patient is hereby advised that the care provided by practitioners through HAMILTON HEALTH & WELLNESS, LLC (the “Practice”) is not a replacement for an in-person primary care relationship with a physician. If the Patient does not have a primary care practitioner, they are advised to seek the care of one.

The Patient understands the following with respect to telehealth offered by the Practice:
The Patient has elected to have a telehealth visit instead of an in-office visit at the Practice. The Patient agrees that the Practice will determine whether the Patient’s condition is appropriate for telehealth and acknowledges that the Practice may recommend an in-person visit.

The Patient has had an opportunity to review the Practice’s providers’ credentials and selected his or her preference for provider.

There are potential risks associated with the use of telehealth, including, but not limited to: the information transmitted may be less comprehensive than that available during an in-person visit and may therefore result in decreased accuracy of diagnosis or medical decision-making; delays in medical evaluation or treatment could occur due to deficiencies or failures of the telemedicine equipment; security protocols could fail, causing a breach of privacy.

The Patient understands that telehealth often involves electronic transmission of the Patient’s protected health information (“PHI”). The Patient’s PHI includes, but is not limited to, the Patient’s identifying information; medical history; diagnoses; communications to and from the Patient’s other health care provider(s); etc. The Patient understands that PHI may be lost due to technical failures, cyber intrusion or other issues disrupting the Patient’s telehealth visit or causing delays in response from the Practice. The Patient assumes these risks and holds the Practice and its providers harmless from any claims arising out of the use of telehealth to conduct the visit. The Patient understands that PHI obtained during the telehealth visit will not be disclosed to others without the Patient’s consent unless permitted by applicable law and in accordance with the Practice’s Notice of Privacy Practices. The Patient has the right to request that we submit information about his or her treatment with the Practice to his or her primary care physician. If the Patient makes such a request and consents to the disclosure of PHI, the Practice will send the Patient’s medical record, and/or a report containing an explanation of the
Patient’s treatment, to the Patient’s primary care physician within 72 hours of his or her consultation with the Practice.

The Patient has the right to withhold or withdraw consent for telehealth at any time without affecting the right to the Patient’s future care, treatment, benefits, or programs for which he or she is otherwise entitled. The Patient understands that if others are present at Patient’s location during the Patient’s telehealth visit, the confidentiality of the Patient’s telehealth visit may be compromised.

The Patient understands the alternatives to telehealth, such as an in-person encounter, as they have been explained, and in choosing to participate in a telehealth visit understands that some parts of the exam may require physical testing to be performed at another location at the direction of the Practice.

THE PATIENT UNDERSTANDS THE PATIENT WILL BE RESPONSIBLE FOR PAYMENT. THE PRACTICE DOES NOT ACCEPT INSURANCE. ALL OUT-OF-POCKET EXPENSES ASSOCIATED WITH THE TELEHEALTH VISIT ARE DUE PRIOR TO THE TELEHEALTH VISIT.

The Patient understands that he or she must be physically located in the state they have listed on their initial profile during his or her telehealth consultation(s) and represents that he or she is actively in that state during the entirety of each telehealth visit. The Patient understands that if he or she is not physically located in their home state, the Practice may decline to treat him or her via telehealth.

The Patient understands that the Practice’s healthcare professionals may prescribe medically appropriate medication to the Patient specifically to treat the Patient’s diagnosed condition, but there is no guarantee that the Patient will be prescribed medication. If medication is prescribed, the Patient, at all times, has the ability to request that his or her medication be fulfilled at the pharmacy provider of the Patient’s choice.

The Patient has been advised of all the potential risks, consequences, and benefits of telehealth. The Patient has been afforded the opportunity to ask questions about the information presented on this form. All the Patient’s questions have been answered, and he or she understands the information contained herein.

I can contact the Practice by faxing my request to (407) 550-5441 for a copy of this form.