Telemedicine phone calls should never be used for emergency communications or urgent requests.
If you are experiencing a medical emergency, please call 911.

▪ Telemedicine is healthcare provided by any means other than a face-to-face visit. Medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications.
▪ Telemedicine involves the exchange of medical health information in a technology-assisted format to provide remote clinical services to patients. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telemedicine services.
▪ Telemedicine communications carries some level of risk of breach of confidentiality, and it is important to use a secure network with any electronic exchange. Our telemedicine visits are typically performed through our HIPPA compliant electronic medical record platform. During the COVID-19 public health emergency, regulatory agencies have allowed for telephone visits and telemedicine visits through platforms such as Skype to allow for greater access to medical care but may not provide a secure HIPAA-compliant platform. Electronic communication may also be used to communicate highly sensitive medical information. I understand I must take reasonable steps to protect the unauthorized use of electronic communications by others and the healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.
▪ All telemedicine visits are billed in the same manner as a regular office visit. While we attempt to provide the most accurate information possible, eligibility and benefits differ with each patient’s healthcare plan. It is ultimately my responsibility to check with my specific carrier to determine coverage and financial responsibility.
▪ Telemedicine services can only be provided to patients who are residing in the state of at the time of this service.
▪ The Health Insurance Portability and Accountability Act provides safeguards to protect my privacy and there are rules and restrictions on who may see or be notified of Protected Health Information. Information exchanged during my telemedicine visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care and medical information, including medical records. These safeguards are governed by federal and state laws and will be maintained under the privacy rules and regulations required, including the right to access my own medical records.
▪ My healthcare provider may choose to forward or request my information to an authorized third party such as my prescription medication history or insurance carrier for billing and treatment purposes. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications.
▪ I understand and agree a medical evaluation via telemedicine may limit my healthcare provider’s ability to fully diagnose a condition or disease. As a patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing or an in-office visit
▪ I understand I may opt out of the telemedicine visit at any time. This will not change my ability to receive future care
at this office.

Download – Telemedicine Patient Consent Form.pdf