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Telemedicine Informed Consent

 

Last updated: July 24, 2022

 

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Telemedicine services involve the online transmission of health information via telephone calls or secure interactive videoconferencing equipment and devices that allow health care providers to deliver health care services to patients when located at different sites. 

 

This document contains important information on: 

  1. Your consent to receive medical treatment from 1981MD, LLC

  2. Your agreement to use the phone and/or internet based telecommunication platforms to share patient medical information for the purpose of medical consultation/treatment. 

  3. Your agreement that you are 100% responsible for all charges. 

 

Please read carefully. Signing this document represents an agreement between you, the patient, and 1981MD, LLC. If you have any questions or concerns about this document, please contact us via text at 205-259-7035 or e-mail at info@1981md.com.


 

THE NATURE OF THE TELEMEDICINE CONSULT

 

During the telemedicine consultation:

 

  1. A review of your medical history will be performed by a clinician through the use of an online questionnaire, telephone, and/or interactive audio/video videoconferencing. 

  2. Your prescription will be sent to the pharmacy after: (i) medical review and (ii) payment has been received. 

    1. There is a possibility that your prescriptions may be delayed based on: (i) your insurance requiring drug authorizations, (ii) medications being out of stock at the pharmacy, (iii) expensive medication costs and requests to change to an alternative medication

  3. You will receive an email notification that your medication has been sent, along with instructions on how to contact us if there are any questions or concerns about your telemedicine visit. 


 

MEDICAL INFORMATION AND RECORDS

 

All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, not all telecommunications are recorded and stored. Additionally, no patient identifiable images or information from the telemedicine consultation will be sent to any entities without your consent. You can request a copy of your medical records from 1981MD by emailing us at info@1981md.com.


 

CONFIDENTIALITY

 

We will use electronic systems to incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, as well as, include measures to safeguard data. There will always be a risk that our electronic systems may be compromised and it is not 100% possible to ensure that there will be absolutely no breach of data. You should also take reasonable steps to ensure the security of our communications, such as, using a secure internet network and using a password protected electronic device. If we are notified by a 3rd party company we use for the delivery of our telemedicine service that a breach of data has occurred, then we will contact you within 48 hours of us being notified. If you have concerns about confidentiality before, during, or after consultation, please do not hesitate to let your voice be heard; contact us at 205-259-7035 or info@1981md.com


 

RIGHTS

 

You may withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment.


 

BENEFITS AND RISKS OF TELEMEDICINE

 

Benefits include, but are not limited to: 

  1. the ability to access medical care without being in the same physical location as the clinician

  2. quicker access to medical care through reduced travel and visit time

  3. ensuring continuity of care during the COVID-19 pandemic as the patient and clinician are likely in different locations or are otherwise unable to continue to meet in-person     

 

Risks include, but are not limited to: 

  1. Confidentiality: At 1981MD, we take reasonable precautions to ensure your privacy, such as using software with encryption and taking the consultation in a private area so the conversation cannot be overheard by other parties. In rare cases, security protocols could fail, causing a breach of personal medical information. It is also important for you to find a private place for our session where you will not be interrupted, nor overheard by other parties. 

  2. Technology: There is the possibility that the internet, video conferencing platform, or EMR may malfunction and interrupt our services resulting in delays in medical care. In rare cases, a lack of access to complete medical information may result in adverse drug interactions, allergic reactions, or other judgment errors. 

  3. Physical Exam: the clinician is unable to perform a hands-on physical examination of you [patient]

 

The alternative to telemedicine is to receive care in a traditional in-person care setting.


 

ELECTRONIC COMMUNICATIONS 

 

1981MD Telemedicine requires that you use an electronic device for communication purposes. This device may be a desktop computer, laptop, tablet, or cellphone with or without a camera. You are solely responsible for any cost required to obtain the necessary equipment to participate in our telemedicine service.

 

Outside of consultations, we communicate with you regarding administrative matters primarily via email communication and secondly, via text messaging with your permission. These administrative matters include, but are not limited to: (1) appointment scheduling, (2) billing, (3) prescription confirmations, (4) concerns or issues that you are having with our telemedicine service, (5) and other related issues. We cannot guarantee confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical/medical information by email or text and prefer that you do not either. We will discuss clinical/medical information by phone or video.


 

TECHNOLOGICAL FAILURES 

 

If the session is interrupted for any reason, such as a technological connection failure, we will wait two (2) minutes and then reconnect with you via phone or the telemedicine platform on which we agreed to conduct the consultation. If we are still unable to reconnect with you due to platform failure, then we will email or text you with information on how to connect to a backup telemedicine platform within 2 minutes after the second attempt at reconnection.


 

BILLING

 

1981MD is a direct care practice meaning that we do not contract with insurance companies and there will be no co-pays due; only a flat fee that you are 100% responsible for. We are aware the people are experiencing financial hardships during this time and have set up a four (4) question survey for those inquiring about reduced consult fees. This survey can be found on the 1981MD telemedicine page. After completion of that survey, you will receive an email notification informing you of your eligibility for discounted services. 

 

The telemedicine consultation fee can be paid: (1) at the time of submission of your consultation questionnaire, (2) after clinician review of your submitted medical questionnaire, or (3) after speaking with the physician via the phone or video conferencing. The consult fee must be paid before a prescription will be sent to the pharmacy.


 

PRIVACY NOTICE 

 

1981MD will protect the privacy of my health information and will not use or disclose it except as permitted by law. 1981MD, LLC’s privacy policies are described in full on our website and is available for review at: https://www.1981md.com/privacy-notice-1

 

By signing this consent, I acknowledge receipt of the Privacy Notice and consent to 1981MD’s use and disclosure of my health information in accordance with its terms. 


 

INFORMED CONSENT

 

  1. I understand that telemedicine treatment has potential benefits and risks as listed above.

  2. I understand that I will not physically be in the same room or location as the clinician.

  3. I understand that the same standard of care applies to a telemedicine visit, as applies to an in-person visit.  

  4. I understand that telehealth has been found to be effective in treating a wide range of disorders, however, there is no guarantee that the treatment given by 1981MD will be successful and I may have to be seen in-person for an evaluation and secondary treatment. 

  5. I understand that telemedicine may not be appropriate for the level of care required for my medical condition and it may necessitate that I be evaluated in-person at an outpatient clinic (Primary Care or Urgent Care) or in the nearest Emergency Department. I understand that the clinician will notify me before or during the telemedicine consultation if this is necessary.

  6. I further understand that clinician’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that the clinician relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

  7. I understand that I cannot use 1981MD, LLC to get prescriptions for DEA controlled substances, non-therapeutic drugs, and certain other drugs which may be harmful because of their potential for abuse.

  8. I understand that the clinician is licensed to practice in the state in which I am receiving services and I will report my location truthfully and accurately during registration.

  9. I understand that I am responsible to ensure privacy at my location and I am responsible for information security on my personal devices that I use to communicate with 1981MD.

  10. I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices [ie. Alexa, Echo, etc.] will be disabled or will not be in range as to not pick up confidential information.

  11. I agree that I will not record any of the session through audio or video, unless it is agreed upon by me and the physician prior.

  12. I understand that I may contact 1981MD via email and text regarding general issues, but I will need to call to discuss specific details regarding my medical condition.

  13. I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption and/or a delay in care.

  14. I understand that if it is determined that the videoconferencing equipment and/or connection is not adequate, the clinician or I may discontinue the telemedicine visit and make other arrangements to continue the visit. 

  15. I understand that 1981MD or I can discontinue a phone/video consult if it is determined that there is a potential for a breach of confidentiality or safety risk (ie. driving during a video consult).

  16. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

  17. I understand that the laws that protect privacy and the confidentiality of healthcare information apply to telemedicine services.

  18. I will not hold 1981MD responsible for lost information due to technological failures. 

  19. I am aware that I can ask questions regarding this telemedicine informed consult at any time prior to signing this document. I am also aware that I can access this on the website at: www.1981md.com/telemedicine-informed-consent

  20. I understand that this document will become a part of my medical record. 

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By signing this document, I acknowledge all that is listed above and that:

  1. 1981MD, LLC is NOT an emergency service. In the event of an emergency, I will use a phone to call 911 or go immediately to the closest emergency room.

  2. 1981MD is a direct care practice and I am 100% responsible for the consultation fee.

  3. I will not share my telehealth appointment link or information with anyone else in order to maintain confidentiality


 

I attest that I: (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions, if i have any, answered to my satisfaction; (3) the risks, benefits, and alternatives to telemedicine visits have been shared with me in a language I understand; and (4) I am located in the state of Alabama/Mississippi/Tennessee/Florida during my telemedicine visit(s).

 

Signature of patient

 

Printed Name of patient

 

Date

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