Telemedicine Informed Consent

In order to communicate with you by email or text message, I need to make sure you are aware of the confidentiality and other issues that arise when we communicate this way and to document that you are aware of these and agree to them. I understand that all email messages are sent over the internet and are not encrypted, are not secure, and may be read by others. I understand that email communications with Peak Family Practice will NOT been encrypted and, therefore, Peak Family Practice can NOT guarantee the confidentiality and security of any information I send to her or that he/she sends to me via email. I understand that SMS messages are even less secure than email, and the same conditions apply. I understand that for this reason my provider has advised me not to send sensitive information via email or SMS messaging. This includes information about current or past symptoms, conditions, or treatment, as well as identifying information such as social security numbers or insurance identification information. I hereby give permission for my provider to reply to my messages via email, including any information that he/she deems appropriate, that would otherwise be considered confidential. I agree that Leslie M Dawdy, FNP-BC or Peak Family Practice will not be liable for any breach of confidentiality that may result from the use of email via the internet. I understand that Peak Family Practice will limit SMS messages to brief inquiries or responses regarding scheduling. I understand that Leslie M Dawdy, FNP-BC or staff at Peak Family Practice may at times email me information about resources that I can use as part of my treatment. I hereby consent to receive such information via email. I understand that email and SMS communication should not be used for urgent or sensitive matters since technical or other factors may prevent a timely answer. I understand that if I use email or SMS to make or request scheduling changes it is my responsibility to confirm that Leslie M Dawdy, FNP-BC has received my communication more than 24 hours before the appointment time being changed. If I believe I need a response within 48 hours, I will not use email but will call my provider. If I don’t receive an answer to a routine email or text message within two working day, I understand that I should call my provider. I understand that all email and SMS communications may be made part of my permanent medical record and would be accessible anyone given access to those records. I also understand that I may withdraw permission for my provider to communicate with me via email or SMS by notifying Leslie M Dawdy, FNP-BC and Peak Family Practice in writing.

• The patient may refuse telemedicine services at any time, without loss or withdrawal of treatment;
• All applicable confidentiality protections shall apply to the services;
• The patient shall have access to all medical information from the services, under state law.”

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 sub-specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: · Patient medical records · Medical images · Live two-way audio and video · Output data from medical devices and sound and video files 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. Expected Benefits: · Improved access to medical care by enabling a patient to remain in his/her ophthalmologist’s office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites. · More efficient medical evaluation and management. · Obtaining expertise of a distant specialist. Possible Risks: 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, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); · Delays in medical 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 medical information; · In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

By signing this form, I understand the following: 1. 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. 2. 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. 3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee. 4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. Peak Family Practice has explained the alternatives to my satisfaction. 5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state. 6. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers. 7. 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 have read and understand the information provided above regarding telemedicine, have discussed it with my provider 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 Peak Family Practice to use telemedicine in the course of my diagnosis and treatment.