Maruthi Pediatrics - Telemedicine Consent Form

• PATIENT AUTHORIZATION AND CONSENT FORM - FOR TELEMEDICINE SESSIONS

  MARUTHI PEDIATRICS PROVIDER: Dr. Badri Donthi (Board Certified Pediatrician)

• Patient Name

  Patient Name * First Last
• Patient Phone

  Patient Phone * - ### - ### ####
• Patient Date of Birth

  Patient Date of Birth * / MM / DD YYYY

  
• Patient/Guardian Email *

• General Information

  ● Telemedicine lets a doctor or other healthcare provider care for you, even when you cannot see him or her in person. The doctor uses the Internet or a technological tool to give you advice, perform an exam, or even do a procedure (check heart rate, etc). Telemedicine can also be used for prescription refills, book an appointment, or to let your doctor talk with other providers about your health problem or treatment.
  ● Before you can have a session, the Telemedicine provider will decide if your health problem can be helped with Telemedicine. Also, providers will be sure to have a backup plan in case of a health emergency.
  ● If you agree, part of your health record may be sent to the Telemedicine provider before your session for their review.
  ● If the patient is a minor child, the Telemedicine provider will explain to the parent how a Telemedicine exam is different from an in-person exam. He or she will also explain if a complete evaluation of the child is possible.
  ● Telemedicine is more than audio-only, phone call, email, fax, or an online questionnaire.
  ● Sometimes you may need to come to a medical facility to use their equipment (TV screen, camera, and Internet) or for formal evaluation / thorough exam

• More Facts

  ● The main goal of telemedicine is to provide you with high quality, personal health care, even though you are not seeing the provider in person.
  ● Before your session, you will learn about which drugs the providers can and cannot prescribe. They must follow the same laws for prescribing drugs as they would for an office visit.
  ● Having a telemedicine session is your choice. Even if you have agreed to the session, you can stop your medical records from being sent - if this has not happened yet. You can refuse or stop the session at any time. You can limit the physical exam.
  ● You will be told about all staff who will take part in the session (if any, or other than provider). You can ask that any of these people leave the room and stop them from seeing or hearing the session. Likewise, the provider may ask if you are the only one partaking in your session, and may also reserve the right to request non-patients (other than legal guardians) to leave the room.
  ● Your session may end before all problems are known or treated. It is up to you to follow up for more care if your health problem does not go away.
  ● Before your session, you may want to ask how much of the cost will be covered by your insurance and how much you may owe.

• Insurance & Payment

  At the time of the telemedicine visit, Medicaid and TRICARE families will pay their usual copay and deductibles, as they would for an in-person office visit. Families with all other insurance coverage will pay $50 and charges will be submitted to your insurance company. Depending on how your insurance company covers telemedicine visits, you may have additional responsibilities, or you may be eligible for a partial refund. Your insurance carrier will make this determination. By signing this consent, you are agreeing to pay $50 towards your visit.

• Telemedicine Session

  During your Telemedicine session:
  ● The provider and the staff will introduce themselves.
  ● The provider may talk to you about your health history, exams, x-rays, or other tests. Other providers may take part in this discussion.
  ● A visual and/or partial physical exam may take place. This may happen by video and/or audio or with other technology tools. A nurse or other healthcare staff may be in the room with you to help with the exam
  ● Non-medical staff may be in the room to help with the technology.
  ● Video and/or photo records may be taken, and audio recordings may be made.
  ● The provider will take notes, and a report of the session will be placed in your doctor's medical record. You can get a copy from your doctor. All laws about the privacy of your health information and medical records apply to Telemedicine. These laws also apply to the video, photo, and audio files that are made and stored.

• Risks and Common Problems

  Many patients like Telemedicine because they do not have to spend time and money on travel to see a healthcare provider in person. Also, they can see a provider who they might not be able to see otherwise. Technology can make getting health care easy, but there can also be some problems:
  
  ● If there are equipment or Internet problems, then your diagnosis or treatment could be delayed.
  ● Records or images that are taken and sent may be of poor quality. This can delay or cause problems with your diagnosis or treatment.
  ● The records sent for review before the session may not be complete. If this happens, then it may be hard for the Telemedicine provider to use his or her best judgment about your health problem. For instance, you could react to a drug or have an allergic response if the provider does not have all of the information that he or she needs.
  ● There could be problems with Internet safety ("hackers"). If this happens, then your medical records may not stay private.
  ● If there is a technology problem, the information from your session may be lost. This would be outside the control of your doctor and Telemedicine provider.
  ● Without a "hands-on " exam, it may be hard to diagnose your problem.
  ● You may still require an ‘in-person’ office visit if the provider deems a personal visit is needed to help diagnose or treat a medical problem

• Patient Consent To The Use of Telemedicine

  This form/email gives me the “facts about” and “risks of” Telemedicine sessions. By (electronically or manually) signing this form (e-signature), I agree that I have read, understood, and acknowledged the terms provided (via email, attachment, print or this form) with regard to “PATIENT AUTHORIZATION AND CONSENT FORM - FOR TELEMEDICINE SESSIONS" section. I also confirm by my signature below that (i) I have been able to ask questions about Telemedicine sessions, (ii) all of my questions have been answered, (iii) I have been told the name and credentials of my Telemedicine provider, and (iv) I agree to take part in a Telemedicine session.
  I have read and understood the policies set forth in this form and agree to adhere to your policies. I have also been provided an opportunity to review or have received the notice of privacy practices, patient authorization and consent form for Telemedicine sessions, and authorization for the release of identifying health information.
  An e-signature can be accepted if your signature matches an official state/federally issued identification with photo ID (e.g. driver’s license or passport) on file.

• I consent to the above Telemedicine policy. *
  I consent to the above Telemedicine policy.

  Yes
• Date

  Date * / MM / DD YYYY

  
• Initial below by patient (or person authorized on behalf of the patient)