Informed Consent

LEGAL

PRIMAHEALTH

INFORMED CONSENT

To better serve the needs of patients, health care services (including mental and behavioral health services) are now available by interactive video communications, audio communications, and/or by the electronic transmission of information. This may assist in the evaluation, diagnosis, management, and/or treatment of a number of health problems. This process is referred to as “telemedicine” or “telehealth.” This means that your health problems may be evaluated, diagnosed, managed, and/or treated by a health care provider or a specialist from a distant location. Since this may be different than the type of consultation with which you are familiar, it is important that you understand and give your informed consent to the use of telemedicine in your care.

DISCLAIMER: Telemedicine is not appropriate for a medical, mental health, or behavioral health emergency. For a medical emergency, dial 911 for assistance. For an emotional emergency, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255); or (v) if applicable, contact the Crisis Text Line (text “GO” to 741-741).

Telemedicine (Including Telebehavioral Health):

Telemedicine involves the use of electronic communications to enable health care providers at different locations to (i) evaluate, diagnose, manage, and/or treat health (including mental and behavioral health) problems and (ii) share individual patient medical information for the purpose of improving patient care. For purposes herein, health care providers may include primary care practitioners (including nurse practitioners), psychiatrists, psychologists, licensed professional counselors, and social workers, all of which may also be referred to as clinicians. The information may be used for evaluation, diagnosis, management, and/or treatment (including therapy), as well as follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way video and/or audio
• 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.

Responsibility for patient care should remain with the patient’s primary care physician or other local clinician, if the patient has one, as does the patient’s full medical record.

Expected Benefits:

Improved access to medical care by enabling a patient to remain in his/her local health care site (e.g., home or work) while the health care provider consults and/or obtains test results at distant/other sites More efficient medical evaluation and management
Obtaining the 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

Patient Rights:

You have the right to:

• Be treated with dignity and respect
• Ask questions and get answers about services
• Participate in all phases of treatment and request changes to treatment
• Be informed of your progress, treatment choices, and any risks/benefits of treatment
• Consent to or refuse treatment (except in an emergency or by court order) and be informed of any potential consequences
• Not be subjected to verbal, physical, emotional, sexual, or financial abuse
• Ask about the health care provider’s qualifications, licenses, education, training, experience, and membership in professional groups and limits of his/her practice
• Receive written information, before entering therapy, about confidentiality and its limits, fees, method of payment, insurance coverage, substitute therapists (in cases of vacation and emergencies), and cancellation policies
• Review or ask for a copy of your medical records, and ask that they be amended or corrected
• Decide who may be involved in your treatment
• Refuse to answer any questions or give any information.
• Be informed as to what behaviors or violations could result in termination of services
• File a grievance or make suggestions about how services could be improved
• Request services from someone with training or experience from a specific cultural, spiritual, or gender orientation (if these services are not available, you will be helped in the referral process)

Patient/Clinician Relationship:

You and your clinician have a professional relationship existing exclusively for medical or therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. Your clinician can best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship.

By checking the box indicating that you agree to the terms of this Informed Consent, you acknowledge that you understand and agree with the following:

1. I understand that the laws that protect privacy and the confidentiality of medical (including mental and behavioral health) 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. However, information may be released without my consent in cases of medical (including mental and behavioral health) emergency, abuse, neglect, court order, insurance billing claims requirements, adult and program evaluation, and where otherwise legally required.
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 health care 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 my health care information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will maintain the 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: (i) omit specific details of my medical history/physical examination that are personally sensitive to me; (ii) ask non-medical personnel to leave the telemedicine examination room; and/or (iii) terminate the consultation at any time.

 

ELECTRONIC SIGNATURE

I have read this Informed Consent form (including, but not limited to, the risks and benefits associated with teleconferencing by video, audio, or other electronic means) and I understand it. All of my questions have been answered to my satisfaction and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.

I understand and acknowledge that my ability to access the PrimaHealth Service is conditional upon the above-mentioned criteria of my informed consent, and that PrimaHealth’s health care providers are relying upon this informed consent in order to interact with and facilitate health care services to me.

 

EFFECTIVE AND REVISED 01/30/2023