INFORMED CONSENT FOR TELEMEDICINE SERVICES
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow‐up and/or education, and may include any of the following:
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
By signing this form, I attest to and understand the following:
PATIENT CONSENT TO THE USE OF TELEMEDICINE
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
I hereby give my informed consent for the use of telemedicine in my medical care.
I hereby authorize (name of Physician) to use telemedicine in the course of my diagnosis and treatment.
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