TELEHEALTH CONSENT FORM
Last Updated: August 9, 2024
I understand that telehealth is a mode of delivering healthcare services via communication technologies (e.g, Internet or cell phone) in order to facilitate diagnosis, consultation, treatment, education, care management and self-management of a patient's healthcare (collectively, "Telehealth Services"). Your agreement to this Telehealth Services Consent Form is a prerequisite to accessing and using Telehealth Services facilitated by TE MARKETING SOLUTIONS LLC and its owners and affiliates (collectively "Company," "our," "us" or "we"). Company has contracted with a third party telehealth services provider ("Telehealth Service Provider") to provide Telehealth Services as described herein.
By acknowledging my consent to this Telehealth Services Consent Form, I understand and agree to the following:
1. I understand that the Telehealth Service Provider offers telehealth consultations, which are conducted through videoconferencing, telephonic and asynchronous technology and that my telehealth provider will not be present in the room with me.
2. I understand there are potential risks to the use of telehealth technology, including but not limited to, interruptions, delays, unauthorized access and or other technical difficulties. I understand that either my telehealth provider or I can discontinue the telehealth appointment if the technical connections are not adequate for my visit.
3. I understand that I could seek an in-office visit rather than obtain care from a telehealth provider, and I am choosing to participate in a telehealth consultation with a qualified medical professional contracted by the Telehealth Service Provider.
4. To protect the confidentiality of my health information, I agree to undertake my telehealth consultation in a private location, and I understand that my telehealth provider will similarly be in a private location.
5. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
6. In an emergent situation, I understand that the responsibility of my telehealth provider may be to direct me to emergency medical services, such as an emergency room.
7. By acknowledging my agreement below, I certify (a) that I have read this form and/or had it explained to me; (b) that I understand the risks and benefits of a telehealth appointment and associated Telehealth Services; and (c) that I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.
By signing below, I consent to receive electronic mail or text messages from the practice at my phone number or email in order to receive appointment reminders and general health reminders or information. I understand that this request to receive emails and/or text messages will apply to all future appointment reminders, feedback or communication of health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.
By using the Telehealth Services facilitated and coordinated through Company, you also agree and acknowledge that Company is a beneficiary of this Telehealth Consent Form and has the right to enforce it as necessary.
State-Specific Disclosures
The following disclosures are required by the states listed below. If you want to file or register a formal complaint against a provider in the following states, please visit the state medical board's website, as listed below:
- Iowa: https://medicalboard.iowa.gov/consumers/filing-complaint
- Kentucky: https://kbml.ky.gov/grievances/Pages/default.aspx
- Maine: https://www.maine.gov/md/complaint/file-complaint
- New York: https://www.health.ny.gov/professionals/doctors/conduct
- Oregon: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx
- Rhode Island: https://health.ri.gov/complaints/
- Texas:
NOTICE CONCERNING COMPLAINTS- Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.
- Vermont: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint or https://sos.vermont.gov/opr/complaints-conduct-discipline/, as applicable.
- Wyoming: http://wyomedboard.wyo.gov/consumers/file-a-complaint
- All other states: https://www.fsmb.org/contact-a-state-medical-board/