Telemedicine Consent

Odyssey Travel Health, PLLC

Informed Consent for Telemedicine Services

 

Description of Telemedicine Services: “Telemedicine” refers to health care services provided by Odyssey Travel Health, PLLC (“Practice”) using two-way, interactive audio and video communications or audio-only communications. Please note the following information about telemedicine services:

 

  1. Upon scheduling a telemedicine appointment, you will receive information by email or text message about how to initiate your appointment at the scheduled time. 

  2. Your provider will always be in a secure and private location to provide telemedicine services. You must also be aware of your surroundings when telemedicine services are provided to you. It is your responsibility to choose a location where your conversations with your provider cannot be overheard by others.

  3. For videoconference appointments, you will need to connect to the session using a cellular data plan or a Wi-Fi network. We recommend that the Wi-Fi network you use require a password that is not publicly available or publicly displayed. Failure to use a secure Wi-Fi network increases the risk for a breach of the privacy and security of your medical information.

  4. You release Practice from all claims, damages, losses, and expenses arising out of your failure to use a private and secure location and communication method while engaging in telemedicine services, including, but not limited to, claims, damages, losses, and expenses arising from your use of an unsecure Wi-Fi connection. 

  5. Standard data and message rates will apply. Practice will not reimburse you for costs of the telemedicine services.

 

Benefits: The anticipated results and benefits of telemedicine services are to effectively and efficiently assist you with the care, management, and treatment of your health condition(s).  

 

Risks: There are risks of telemedicine, including but not limited to, the possibility that the transmission of your medical information could be interrupted, disrupted, or distorted based on technical failures; your information could be accessed by unauthorized persons based on failures in the security protocols of the telemedicine technology; and/or, your provider’s inability to evaluate you in person could lead to inaccurate assessment of your health condition(s). Your provider may determine that telemedicine services are not appropriate or sufficient for you, and in that case, she will recommend alternative treatment options. 

 

Alternatives: Alternatives to receiving telemedicine services include scheduling an in-person appointment. Please understand, however, that your provider may not be able to see you immediately for an in-person appointment, so your treatment may be delayed. Another alternative to telemedicine is to not receive any treatment, but this could make your health condition(s) worse.

 

Text and Phone Call Consent: By your signature below, you consent to Practice’s transmission of calls and unencrypted text messages at the cell number below, and unencrypted email messages at the email address below, related to the Practice’s services, including telemedicine services.  Unencrypted communications carry certain risks. For example, text messages and emails could be received by other people who have access to your device. By your signature below, you acknowledge that these risks exist and expressly consent to receive unencrypted communications described in this Consent from Practice. 

 

Cell number: _____________________________________

Email address: ______________________________________

By my signature, I, the patient designated below, understand the above description of the telehealth services, the potential benefits and risks of telehealth, and the possible treatment alternatives. I certify that I have had the opportunity to ask questions and consent to receiving telehealth services from Practice.

Patient Name

Signature___________________________________________________________  Date

Address, City, State, Zip Code:

Name/Relationship of Authorized Signer (if other than patient):

 

Date Last Revised: December 15, 2022