CONSENT FORM

Barbara A. Walker, MD, MPH

Telehealth Review Consultation

A telehealth review consultation allows clinicians to provide a diagnosis, additional information and recommendations using your existing medical records, and possibly video or audio conferencing via telephone or computer.

Purpose

The purpose of this Consultation Consent Form is to get permissions from patients in order to participate in telehealth consultation services.

Confidentiality

Telecommunications with patients will not be recorded and stored. Patients' medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies. Medical and personal information of patients are protected by the state and governmental laws.

Risks and Benefits

The medical information related to history, records and tests of the patient will be discussed during the telemedicine appointment with written, video and/or audio communication. Telehealth consultation aims to provide a complete assessment and recommendations to patients regarding their existing health concerns. It may not always be beneficial and there is no guarantee that the consultation will be effective for patients.

Access

The patient accepts that he/she needs access to a PC, laptop, or mobile device and a good internet connection in order to have an efficient telehealth appointment.

Payment

Patients agree that they are responsible for paying all costs as agreed upon for services provided. (Insurance is not accepted.)

Patient Rights

The patient can withdraw his/her consent at any time and can ask questions related to telemedicine appointments and technical requirements for telecommunication.

Consent

By signing,

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures.

I understand that I may be charged fees that my insurance does not cover.

I accept that I authorize health care professionals to use telemedicine for my evaluation and recommendations.

I represent that I am authorized and have permission to provide all information included in the intake process, including all uploaded documents.