Informed Consent for Telehealth Services

Informed Consent

Telehealth

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information to improve patient care. Telehealth services offered by MMG Medical Group, PA (collectively “MMG”), may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

 

The electronic communication systems we use 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 ensure its integrity against intentional or unintentional corruption.

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MMG providers, including physicians, nurse practitioners, nurse midwives, physician assistants, and naturopathic doctors (our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.


Email Communication

Our office will use reasonable means to protect the security and confidentiality of email
information sent and received—however, we cannot guarantee the security of email
communication. Thus, patients must consent to the use of email for patient information, billing,
and communication. Consent to use email includes agreement with the following conditions:

  • Emails to or from the patient concerning treatment may be printed in full and made part of the patient’s medical record. Because they are part of the medical record, authorized individuals will have access the medical record/email (e.g. billing staff).
  • Our office may forward emails internally to those involved, as necessary, for healthcare operations and other handling. Our therapists will not forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law.
  • Although our office will endeavor to read and respond promptly to all emails from the patient, it is not guarantee that any particular email will be read and responded to within any particular period of time. The patient should not use email for medical emergencies or other time-sensitive matters.
  • If the patient’s email invites a response from the provider and a response is not received
    within a reasonable time period, it is the patient’s responsibility to follow up.

Transmitting patient information poses several risks and the patient should not agree to
communicate with the provider via email without understanding and accepting these risks.
The risks include, but are not limited to, the following: 

  • The privacy and security of email communication cannot be guaranteed.
  • Email senders can misaddress, resulting in it being sent to many unintended recipients.
  • Employers/online services may have a legal right to inspect and keep emails that pass through their system.
  • Even after deletion of the email, backup copies may exist on a computer.
  • Email is easier to falsify than signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email.
  • Emails can introduce viruses, generally damage, or disrupt the computer.
  • Email can be used as evidence in court.

Expected Benefits:

  • Improved access to care by enabling you to remain in your home.
  • More efficient care evaluation and management.
  • Obtaining the expertise of a specialist as appropriate.

‍Possible Risks:

  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
  • In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
  • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare events, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.


If you need to receive follow-up care, or assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact MMG at [email protected].

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By scheduling a telehealth appointment, you acknowledge that you understand and agree with the following:

 

  1. I have read this Informed Consent to receive services via telehealth carefully, and understand the risks and benefits of the use of telehealth in my medicare care and treatment.
  2. I hereby consent to receive MMG’s services via telehealth technologies. I understand that MMG and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the MMG provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
  3. I understand that in some cases, my provider may be a nurse practitioner, nurse midwife, physician assistant, or naturopathic doctor, and not a physician.
  4. I understand that federal and state law requires health care providers to protect the privacy and security of health information. I understand that MMG will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
  5. I understand there is a risk of technical failures during the telehealth encounter beyond the control of MMG. I agree to hold harmless MMG for delays in evaluation or for information lost due to such technical failures.
  6. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate the use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the MMG providers are not able to connect me directly to any local emergency services.
  7. I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or a testing facility, at the direction of the MMG provider (e.g. labs or bloodwork).
  8. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  9. I understand that I cannot obtain emergency care through the services, and I should call 9-1-1 and seek immediate medical treatment if I am experiencing a medical emergency.
  10. I understand that my healthcare information may be shared with other individuals for treatment, scheduling, and billing purposes. Persons may be present during the consultation other than the MMG provider to operate the telehealth technologies. 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/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
  11. I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
 

I understand that if I participate in a consultation, I have the right to request a copy of my medical records which will be provided to me at a reasonable cost of preparation, shipping, and delivery.

Patient Consent

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

 

By scheduling my telehealth appointment, I hereby state that I have read, understood, and agree to the terms of this document.