Telehealth Consent

Information and Informed Consent for telemedicine is live two - way audio and/or video electronic communications that allows providers and clients/patients to meet outside of a physical office setting.

Client:

  • Understands that telemedicine services are completely voluntary and that client can withdraw this consent at any time.

  • Understands that none of the telemedicine visits will be recorded or photographed.

  • Agrees not to make or allow audio or video recordings of any portion of the visits.

  • Understands that the laws that protect privacy and the confidentiality of patients information also apply to telemedicine, and that no information obtained in the use of telemedicine that identifies you the patient will be disclosed to other entities without your consent.

  • Understands that telemedicine is performed over a secure communication system.

  • Understands that any internet based communication is not 100 % guaranteed to be secure.

  • Agrees that the provider and Company (OTMIV) will not be held responsible if any outside party gains access to your personal information by bypassing the security measures of the communication system.

  • Understands there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

  • Understands that you or your provider may discontinue the telemedicine visits at any time if it is felt that the video technology is not adequate for the situation.

  • Understands that if there is an emergency during a telemedicine visit, then your provider may call emergency services and/or your emergency contact.

  • Understands that this form is signed in the consent to treat in addition to the Notice of Privacy Practices and Consent to Treatment agreements and that all office policies and procedures apply to telemedicine.

  • Understands that if the video conferencing connection drops while you are in a visit, your provider will contact you back. During the visit process at times your provider will complete an evaluation over the phone. All providers who call from OTMIV are held to the same company procedures as in person providers. All providers over telemedicine are mandated reporters by law. If you report you might harm yourself or someone else or hang up the phone during session and you have stated risk of harm your provider is permitted and required by Arizona law to break confidentiality to get you help or someone else in foreseeable harms way. In addition, if you are in crisis and you hang up the phone and your provider is unable to contact you again 911 or the nonemergency line will be contacted to respond to you for help.