Telemedicine Consent 

Introduction

Telemedicine involves the use of electronic communications to enable healthcare providers at different locations in obtaining personal health information. This information may be used for diagnosis, treatment and/or education of the patient. Electronic systems used will: incorporate network and software security protocols to protect the confidentiality of patient information; and include measures to safeguard the data and ensure its integrity against corruption. 

Expected Benefits

• Improved access to medical care by enabling a physician to provide medical services to patients that are not at the same location. 
• More efficient medical evaluation and management. 
• Decreased variance from established evaluation and treatment protocols. 

Possible Risks: 

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

• Inadequate data that may require further evaluation 
• Delays in medical evaluation and treatment
• Breach of privacy of personal health information in the very rare case of failure of security protocols
• Adverse drug reactions, Allergic Reactions, Errors in Diagnosis and Errors in Treatment due to lack of access to complete medical records. 

By proceeding with Catalyst’s Medical Evaluation and Order form, you acknowledge, that you understand and agree the information above and with the following: 

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the consulting healthcare provider.
4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
5. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
6. I understand that third-party affiliates may have access to your healthcare information for operational purposes. These parties are obliged to maintain confidentiality and adhere to security protocols to safeguard your personal health information.

If you do not consent to any part of this Informed Consent, you should not proceed with Catalyst’s Medical Evaluation and Order form. 

Last Updated June 9, 2020