This Telemedicine Consent was last updated on June 01, 2021.
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services also include remote monitoring, tele-pharmacy, prescription refills, appointment scheduling, regional health information sharing, and non-clinical services, such as education programs, administration, and public health. 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 combination of the following: (1) patient medical records; (2) medical images; (3) live two-way audio and video; (4) interactive audio; and (5) output data from medical devices and sound and video files.
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.
Primary responsibility for your medical care should remain with your local primary care doctor, if you have one. Your primary care doctor should also maintain responsibility for your medical record as well.
● Improved access to medical care by enabling you to remain in your local healthcare site (i.e. home) while the provider consults and obtains test results at distant/other sites.
● More efficient medical evaluation and management.
● Obtaining expertise of a specialist.
● Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
● In rare events, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a face-to-face 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 or allergic reactions or other judgment errors.
1. I hereby consent to receiving Thrones Health’s services via telehealth technologies. I understand that Thrones Health and its consulting providers offer telehealth 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 Thrones Health provider to determine whether or not my needs are appropriate for a telehealth encounter.
2. I have been given an opportunity to select a consulting provider from Thrones Health prior to the consult, including a review of the consulting provider’s credentials.
3. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Thrones Health 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 medical practitioners who may be located in other areas, including out of state.
4. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Thrones Health. I agree to hold harmless Thrones Health and Providers for delays in evaluation or for information lost due to such technical failures.
5. 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 access to the service 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 Thrones Health health service specialists are not able to connect me directly to any local emergency services.
6. I understand the 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 physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Thrones Health consulting healthcare provider (e.g. labs or blood work).
7. I understand video images and audio recordings of me may be captured and stored electronically. I understand that these recordings may be later viewed and used for purposes of evaluation and training, which may include Thrones Health non-physician personnel and students. I understand and consent to the use of these images and audio recordings for the telehealth consultation and, potentially, evaluation, education and training.
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 my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Thrones Health provider in order 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.
10. I understand that I will not be prescribed any Drug Enforcement Agency controlled substances nor is there any guarantee that I will be given a prescription at all.
11. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
12. I understand that in the event of any problem with the website or related services, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will Thrones Health or any Thrones Health independent contracted affiliated provider (including but not limited to Thrones Health) be liable in any way for the use of the telehealth services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that I will not hold Thrones Health, its subsidiaries or any Thrones Health independent contracted affiliated provider (including but not limited to Thrones Health) liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with your use of the website whether under a theory of breach of contract, negligence, strict liability, malpractice or otherwise, even if we or they have been advised of the possibility of such damages.
13. I understand that Thrones Health makes no representation that materials on this website are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use.
14. If you need to receive follow-up care, 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 Thrones Health at [1- (844) 948-4758] or [firstname.lastname@example.org], and notify your primary care doctor or emergency medical services, as you deem appropriate.
15. Additional Consent: The following consents apply to all users accessing the Thrones Health website for the purposes of participating in a telehealth consultation as required by the states listed below:
I understand that my medical records may be sent to my primary care physician. Regarding complaints to Medical and Nursing board of your state, by filing complaint with you agree to release all medical records for the review complaints to the Medical and Nursing board of your state at time of treatment:
NOTICE CONCERNING COMPLAINTS, Complaints about physicians, as well as other licensees and registrants of the Medical Board of your, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at to the Medical or Nursing Board of your state.
AVISO RELATIVO A LAS QUEJAS, las quejas sobre médicos, así como sobre otros titulares de licencia y personas registradas en la Junta Médica de su, incluidos asistentes médicos, acupunturistas y asistentes quirúrgicos, pueden informarse para su investigación en la Junta Médica o de Enfermería de su estado.
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 checking the Box containing “INFORMED CONSENT FOR TELEHEALTH SERVICES” I hereby state that I have read, understood, and agree to the terms of this document