Telehealth Consent

Informed Consent for Telehealth Services

Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patients’ medical information for the purpose of improving patient care. Providers may include primary care 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 messaging, audio and video
  • Video files, audio files, and phone calls
  • Direct text messaging and email correspondence
  • Invitations to use HIPAA-compliant audio and video chat services
  • Output data from medical devices and sound and video files
  • Files sent to and received from your treating physician (including images, lab results, and clinical documents)

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Responsibility for patient care should remain with the patient’s local clinician, if you have one, as does the patient’s medical record.

About Your Provider

The medical intake form you complete will be reviewed by a board-certified physician licensed in your state. Your treating physician will use the medical intake information to develop a medical treatment plan. Once care begins, your physician retains the ability to send and receive files (including but not limited to images, lab results, and clinical documents) as part of your ongoing care.

Expected Benefits:

  • Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physician consults and obtains test results at distant/other sites.
  • More efficient medical evaluation and management.
  • Obtaining expertise of a specialist.

Possible Risks:

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

  • In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult;
  • 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 medical information;
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

Off-Label and Compounded Medications

Some medications prescribed through OpalRx may be used “off-label,” meaning they are prescribed for a condition or in a manner not specifically approved by the U.S. Food and Drug Administration (FDA). Off-label prescribing is legal, common in medical practice, and used at the discretion of your provider based on clinical evidence and professional judgment. Additionally, some medications may be compounded formulations that are not FDA-approved as finished products. Your provider will inform you if a prescribed medication is being used off-label or is a compounded formulation, and you should discuss any questions or concerns with your provider before beginning treatment.

Your Acknowledgments

By checking the box associated with “Informed Consent,” you acknowledge that you understand and agree with the following:

  1. I confirm that I am the patient seeking care, or I am the legally authorized guardian of the patient, and I am consenting to be evaluated and treated by a physician via telemedicine.
  2. I acknowledge that the information I provide in the medical intake form and throughout my care is accurate, truthful, and complete to the best of my knowledge, and I understand that inaccurate or incomplete information may result in inappropriate treatment or serious harm.
  3. I acknowledge and clearly identify the medical condition, symptom, or reason for which I am seeking treatment through OpalRx.
  4. I understand that my medical intake will be reviewed by a board-certified physician licensed in my state, who will use the information to develop a medical treatment plan.
  5. I consent to receive care via the communication methods described above, including video files, audio files, phone calls, direct text messaging, email, and invitations to use HIPAA-compliant audio and video chat services.
  6. I understand that my physician has the ability to send and receive files (including images, lab results, and clinical documents) as part of my ongoing care, and I consent to this exchange of information.
  7. I understand that some medications may be prescribed off-label or as compounded formulations, and I will discuss any concerns with my physician before beginning treatment.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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, and there is no guarantee that I will be issued a prescription or a specific treatment.
  13. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.

Patient Consent to the Use of Telemedicine

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

I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.