Informed Consent for Telemedicine/Telephonic Services Form

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  • Introduction:
    Telemedicine and Telephonic services, also referred to as Telehealth, involves the use of electronic communications (video and/or audio) to provide medical, behavioral health and wellness services to our patients without an in-person visit. For example, this technology is used for follow-up visits, management of chronic or acute conditions, medication management, and consultation with a behavioral health and wellness specialists. Other authorized individuals may be present during the Telehealth consultation, but only to assist with initial set-up, and ensure technical support for video and audio equipment. Your telehealth consultation will not be recorded or observed unless you consent to such recording or observation in writing in advance. All staff involved in Telehealth consultations adhere to strict federal and state laws and rules regarding the confidentiality of your private health information. Please review Native Health’s Notice of Privacy Practices which describes how we may use or disclose your health information. We recommend that you not include anyone else during the Telemedicine/Telephonic service for purposes of maintaining confidentiality.

    Expected Benefits/Expected Outcome:
    Allows our patients to remain at home or at a remote site to receive health services. More efficient and easier access to health evaluation and management.

    Possible Risks:
    There are potential risks associated with the use of telemedicine. These risks include, but not limited to, information transmitted by audio or video not sufficient (e.g. poor resolution of images, or audio connection) to allow for appropriate medical decision-making by the healthcare provider and/or consultant(s); delays in health 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 your personal health information.

    The alternative to telehealth visits is a face-to-face/in-person visit.

    Suspension/Discontinuation of Telehealth Services:
    Your provider may decide to suspend or discontinue telehealth services if it is felt the service is not adequate for the situation or to meet your needs. In addition...

    Your rights as a patient:

    • To be informed of others present in the consultation (at the provider’s site)
    • To omit specific details of your medical or health history that are personally sensitive
    • Ask that non-medical personnel not take part in the Telemedicine/Telephonic Consultation
    • Terminate the consultation at any time without affecting my future care and/or treatment
    • File a complaint if not satisfied with Telemedicine/Telephonic services: Complaint may be filed with the Compliance Officer at 602-279-5262 ext. 3138
    To refuse telehealth services or revoke orally or in writing at any time your consent to participate in telehealth services with no punitive action taken against you. If you revoke your consent, Native Health will only be able to see you for in-person services.

    I have read and understand the information provided above regarding Telehealth services and have discussed it with my healthcare provider or staff as may be designated. All my questions have been answered to my satisfaction. I hereby give my informed consent voluntarily for the use of Telehealth services in my healthcare and have been offered a copy of this consent form.


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  • NOTE:
    If patient is a minor or in care of a custodian, must be signed by an authorized representative and/or parent or guardian. Please indicate the relationship.

  • If consenting to the use of telephonic and/or telehealth services, patient to complete this section, with initials next to their selection(s):

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