Informed Consent for Telemedicine Services
Last Modified: March 22, 2019
The purpose of this form is to provide you with information about telemedicine and to obtain your informed consent to participate in a telemedicine health service as part of your medical care. Telemedicine services are provided by the practitioners at Scanwell Medical Group, P.A. and its affiliated entities, including Scanwell Medical Group, and may include independent contractors (collectively defined as “Scanwell Medical Group”).
Nature of Telemedicine
Telemedicine involves the use of electronic communications to enable a health care provider and a patient at different locations to share medical information for the purpose of evaluation, diagnosis, consultation, or treatment of the patient. The delivery of healthcare via telemedicine allows the patient and provider to establish a relationship, much as they would during a traditional face-to-face appointment. For example, your telemedicine encounter may include interaction through and with the use of the internet, emails, telephone, recorded audio communications, mobile applications, physical examinations, medical imaging, medical tests, and diagnoses, as well as related technologies known as “store-and-forward.”
The benefits of telemedicine include improved access to medical services and care, including the expertise of specialists and consultants that may not otherwise be available to you. Telemedicine also permits increased efficiency in evaluations, diagnoses, consultations, and treatment.
The potential risks associated with the use of telemedicine are rare, but include delays in medical evaluation and treatment due to equipment failures or information transmission deficiencies (such as poor image resolution); breach of privacy of protected health information due to security breaches or failures; and adverse drug interactions, allergic reactions, complications, or other errors due to patient’s failure to provide complete medical information or records. Missed or inaccurate diagnosis are risks in any healthcare setting and these risks may be amplified in a telemedicine setting due to the inability of the treating practitioner to do an in person physical exam.
Potential Adverse Reactions
The practitioners at Scanwell Medical Group may be providing you with a prescription for treatment, which may include antibiotics. All medications, including antibiotics, have the potential for adverse reactions.
Please note that if you are taking any additional medications there may be the potential for drug interactions between your existing medications and the medications prescribed. By signing this informed consent form you are agreeing to provide an accurate list of all known allergies and prescription and over the counter medications you are currently taking or have taken within the past month. While the physicians, physician assistants, and nurse practitioners prescribing you these medications will check for potential medication interactions, Scanwell Medical Group and its employed healthcare providers are not liable for any harm or damages caused by an adverse reaction caused by these medications directly or any associated medication interactions.
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS SCANWELL MEDICAL GROUP, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO SCANWELL MEDICAL GROUP NEGLIGENCE.
Alternative methods of care may be available to you, such as in-person services. You may choose an alternative at any time.
Follow-up Care and Emergency Situations
In some situations, telemedicine is not an appropriate method of care. If there is an urgent situation, if you have an adverse reaction from a prescribed medication, if a technical failure prevents you from communicating with your telemedicine provider, or if you believe telemedicine will not provide sufficient safety and quality, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. If the situation is an emergency, call 911.
Your Privacy Rights
Scanwell Medical Group uses network and software security protocols to protect the confidentiality of your patient health information, including your medical record and test results. These protocols are designed to safeguard the data and to ensure its integrity against corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in Scanwell Medical Group’s Notice of Privacy Practices.
By signing this form, I understand the following:
Telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand that I need to provide a full and accurate medical history, including any pre-existing conditions, to my telemedicine provider so that my provider can accurately determine what services I need. I further understand that my provider will determine whether telemedicine is appropriate for me at this time, based on the condition being diagnosed and/or treated. I understand that I may benefit from telemedicine, but that results cannot be guaranteed. I further understand that I have the right to object to the use of a telemedicine service without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which I am entitled. Further, I understand and agree that I must pay the full amount of the costs associated with this telemedicine service, including any prescription I may receive, and I will not attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine and I agree that Scanwell Medical Group may provide my confidential personal health information to other medical providers who may be located in other areas, including on rare occasions to providers outside the State, as necessary. I have the right to inspect and obtain copies of all information received and recorded during any telemedicine session, subject to the policies of the physicians, physician assistants, nurse practitioners and facilities involved in my care. I may be charged a fee for copies of my records in accordance with applicable State rules. I have read and understand the information above and all of my questions have been answered to my satisfaction.
I consent to a Scanwell Medical Group physician, physician assistant, or nurse practitioner to provide services to me via telemedicine.
By clicking "I Agree" in the mobile application, I understand and consent to the foregoing acknowledgements and disclosures including Scanwell Medical Group’s Notice of Privacy Practices. Further, for purposes of this informed consent, MY ACT OF CHECKING THE "I Agree" BOX SHALL CONSTITUTE AND IS MY ELECTRONIC SIGNATURE.
If you have any questions, concerns, complaints or suggestions regarding our Informed Consent for Telemedicine Services or otherwise need to contact us, you may contact us at:
800 Wilshire Blvd. Suite 200
Los Angeles, CA 90017