Informed Consent for Services
By scheduling a telemedicine appointment, you acknowledge that you understand and agree with the following:
Delivering telemedicine services involves the use of electronic communications to enable healthcare providers at your Primary Care office to evaluate and treat you at a distant site (home, work, etc). Providers may include primary care practitioners and/or other allied healthcare professionals. The communication may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
- Patient medical records
- Medical images
- Medical test results
- Live two-way audio and video
Electronic systems used will incorporate standard network and software security protocols to protect the confidentiality of patient identification and data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physician consults and obtains test results at distant/other sites.
More efficient medical evaluation and management.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
In rare cases, the medical provider may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult
Delays in medical care could occur due to deficiencies or failures of the equipment
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
Office Policies / Requirements for Telemedicine
We offer telemedicine services for adult patients who are 18 years old and over. Patients must be physically present in Illinois. Telemedicine is not appropriate for emergency conditions, nor can we manage or prescribe controlled substances via telemedicine. Standard office charges apply. We can submit office charges to private insurance but cannot guarantee coverage for telemedicine as coverage details vary from plan to plan. Patients should confirm coverage with their insurance company. Co-payments and deductibles apply. We cannot bill Government insurance plans, such as Medicare and Medicaid for telemedicine visits in our office.
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent.
- I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other staff members for scheduling and billing purposes.