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.
Alternative: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:
CONSENT TO PARTICIPATE: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.
If the patient is a minor or in the care of a custodian, the form 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):