Patient Name: 

Healthcare Practitioner: Accordia Health Credentialed Provider

Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual consumer health information for the purpose of improving consumer care. This consent is valid for twelve months. The information obtained may be used for diagnosis, therapy, follow-up, referral, and/or consultation, and may include one or both of the following:
• Live two-way audio and video
• Output data from medical devices and sound and video files
The interactive tele-video equipment and telecommunication lines used are HIPAA approved for consumer security and privacy.

Expected Benefits
• Improved access to primary care by enabling a consumer to have a session with a provider while remaining at a remote site,
• More efficient medical evaluation and management.

Possible Risks
There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
• Delays in evaluation and treatment 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 health information.

By signing this form, I understand the following:
1. The laws that protect privacy and the confidentiality of primary care information also apply to telehealth, and that no information obtained in the use of telehealth, which identifies me, will be disclosed to other entities without my written or verbal consent.
2. I have the right to withhold or withdraw my consent (either written or verbally) to the use of telehealth in the course of my care at any time.
3. I understand that the health care provider is off site at a remote location.
4. I understand that none of the teleconference will be recorded or photographed.
5. I understand that in the event of technical difficulties an employee of the IT department, as well as additional staff, may be present during my session.
6. I may have to travel to see a health care practitioner in-person if I decline the telemedicine service.
7. If I decline the telemedicine services, all other options/alternatives available will be shared with me by a facility staff member.

8. The information from the telehealth service (images that can be identified as mine or other medical information from the telehealth service) cannot be released to researchers or anyone else without my additional written consent.
9. I will be informed of all people who will be present at all sites during my telemedicine service.
10. I may exclude anyone from any site during my telehealth service.
11. I may see an appropriately trained staff person, or employee, in-person, immediately after the telemedicine service if an urgent need arises. OR, I will be told ahead of time that this is not available.
12. I may contact the healthcare provider for any questions I have related to medical services received through a telemedicine provider/site.

I understand that this consent will expire t
welve months from the signature date or at the time of my discharge from this program, whichever comes first.

I have read this document carefully, and my questions have been answered to my satisfaction.

Printed Name of Patient:

Signature of Patient:

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Printed Name of Parent or Legal Representative:

Signature of Parent or Legal Representative: 

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Created 3/31/2020; Revised Electronically 4/29/2020 NB-226