Name
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Primary Phone #
Alternate Phone #
Address
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Please state your reason for consulting via Telehealth:
Please read the following consent form and sign to indicate that you consent to consulting with our medical providers via telemedicine.
1. I authorize the providers of Marilyn Asistores-Quilon, MDPA to allow me/the patient to participate in a telemedicine consultation.
2. The type of service to be provided via telemedicine is a Family Medicine consultation.
3. I understand that this service is not the same as a direct patient/healthcare provider visit because I/the patient will notbe in the same room as the healthcare provider performing the service. I understand that a part of patient care and treatments which require physical procedures or examinations may be necessary in order for me/the patient to receive proper care as designated by healthcare provider. These procedures or examinations may be ordered before
continuation of care (i.e. prescription for medication, order for imaging or an outpatient service) and it is my responsibility to bring patient physically to a medical facility in order to have ordered examinations or procedures conducted by providers and their staff.
4. My/the patient's physician has fully explained to me the nature and purporse of the videoconferencing technology and has also informed me of expected risks, benefits, and complications (from known and unknown causes), attendant discomforts, and risks that may arise during the telemedicine session as well as possible alternatives to the proposed sessions, including visits with a physician in-person. The attendant risks of not using telemedicine have also been discussed. I have been given an opportunity to ask questions, and all of my questions have been answered fully and satisfactorily.
5. I understand that there are potential risks to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my/the patient's healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation.
6. I understand that the telemedicine session will not be audio or video recorded at any time.
7. I agree to permit my/the patient's healthcare information to be shared with other individuals for the purpose of scheduling and billing. I agree to permit indviduals other than my/patient's healthcare provider to be present during my/the patient's telemedicine service to operate any video equipment if necessary. I further understand that I will be informed of their presence during the telemedicine services. I acknowledge that if safety concerns mandate additional persons to be present, then my or guardian permission may not be needed.
8. I acknowledge that I have the right to request the following: (1) Omission of specific details of my/patient's medical history/physical examination that personally sensitive; (2) Asking non-medical personnel to leave the room being used for consultation at any time if not mandated for safety concerns; (3) Termination of the service at any time.
9. When the telemedicine service is being used during an emergency, I understand that it is the responsibility of the telemedicine provider to advise my/the patient's provider regarding necessary care and treatment.
10. It is the responsibility of the telemedicine provider to conclude the service upon termination of the videoconference connection.
11. I/The patient understand(s) that my/the patient's insurance will be billed by the healthcare provider for telemedicine services. I/the patient understand(s) that if my insurance does not cover telemedicine services, I/the patient will be billed directly by the healthcare provider for the provision of medical consultation services via telemedicine.
12. My/The patient's consent to participate in this telemedicine service shall remain in effect for the duration of the specific service identified above, or until I revoke my consent in writing. Written revocation of consent must be presented to healthcare provider and staff to assure that all parties have been notified of revocation of consent.
13. I/The patient agree that there have been no guarantees or assurances made about the results of this service.
14. I/The patient acknowledge the telemedicine program's no -show policy which states that I/the patient may be discharged from the telemedicine program if I/the patient no-show for 2 consecutive appointments (without prior contact to the scheduling staff at Marilyn Asistores-Quilon, MDPA).
15. I confirm that I have fully read and fully understand all the above. All blank spaces have been completed prior to my signing.
Patient/Relative/Guardian Signature (please type full legal name)
Date
Relationship to Patient (if required)
Submit
