INFORMED CONSENT FOR TELEMEDICINE SERVICES

INTRODUCTION

Telemedicine involves the use of electronic communications that allows health care professionals to evaluate,diagnose and treat patients using telecommunications technology. Telemedicine allows patients to remain in theirhomes or other remote locations to access medical expertise quickly, efficiently and without travel. It isparticularly helpful in the event of a natural disaster or a pandemic when social distancing and travel restrictionsmay prevent patients from visiting a Provider's Office for receiving treatment. Providers may include primarycare practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow up

and/or education, and may include any of the following:

  • Patient medical records
  • Medical images
  • Live two‐way audio and video
  • Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality ofpatient identification and imaging data and will include measures to safeguard the data and to ensure its integrityagainst intentional or unintentional corruption.

EXPECTED BENEFITS

  • Improved and quicker access to medical care by enabling a patient to remain in his/her home (or at aremote site) while the physician consults from a distant/other sites.
  • More efficient medical evaluation and management.
  • Obtaining expertise of a specialist located at a different site.

POSSIBLE RISKS

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risksinclude, but may not be limited to:

  • In rare cases, information obtained during a telemedicine session may not be sufficient to allow forappropriate medical decision making by the physician and consultant(s)
  • Delays in medical 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 personal medicalinformation.
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions orallergic reaction or other judgment error.

BY CHECKING THE BOX RELATED TO INFORM CONSENT, I ATTEST TO AND UNDERSTAND THE FOLLOWING:

  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply totelemedicine, and that no information obtained in the use of telemedicine which identifies me will bedisclosed to researchers or other entities without my consent,
  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in thecourse of my care at any time, without affecting my right to future care or treatment.
  3. I understand that I have the right to inspect all information obtained and recorded in the course ofmy telemedicine interaction and may receive copies of this information for a reasonable fee.
  4. I understand that a variety of alternative methods of medical care may be available to me, and that I havechosen telemedicine fully understanding the risks and benefits.
  5. I understand that telemedicine may involve electronic communication of my personal medical informationto other medical practitioners/consultant physicians who may be located in other areas, including out ofstate.
  6. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that noresults can be guaranteed or assured.
  7. I attest that I am located in the state of New Jersey and will be present in the state of New Jersey during alltelehealth encounters with the physician I have selected during my appointment registration for thetelemedicine consultation.
  8. I also understand that some insurance companies may not cover telemedicine consultations or that I do nothave telemedicine consultation as a covered benefit under my insurance plan. In that event, I will bepersonally responsible for the self-pay rates that is posted on the practice website. I authorize thePhysician to bill me for such services at the self-pay rates and I agree to pay the billed amount immediately.

PATIENT CONSENT TO THE USE OF TELEMEDICINE

I have read and understand the information provided above regarding telemedicine, have discussed it with myphysician or such assistants as may be designated, and all my questions have been answered to my satisfaction.

I hereby give my informed consent for the use of telemedicine in my medical care. I also authorize the physician Ihave selected during my appointment registration for the telemedicine consultation for my treatment.

By checking the Informed Consent check box in the Appointment Selection page, I have electronically signed thisdocument on the date and time of booking the appointment.

If the appointment is created for a minor, I acknowledge that I have electronically signed this document on the dateand time of booking the appointment on behalf of that minor and I have the legal authority to sign this documentation behalf of that minor.

BY CHECKING THE BOX RELATED TO INFORM CONSENT, I HAVE ELECTRONICALLY SIGNED THIS INFORMED CONSENT FORM