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The purpose of this form is to obtain your consent to participate in a telemedicine consultation.

    1. Purpose and Benefits: The purpose of telemedicine is to enable patients to receive medical care from their provider without risk of in-person exposure to COVID-19.

    2. Nature of Telemedicine Consultation: During the telemedicine consultation:

      1. Details of your medical history, examinations, and diagnostic testing results will be discussed.

      2. Visual physical examinations may take place.

      3. Nonmedical technical personnel may be present or become present during the telemedicine visit to aid with anytechnical issues that may occur.

      4. Video, audio and/or digital photo may be recorded during the telemedicine visit and kept as part of your medicalrecord with Embrace Wellness.

    3. Medical Information and Records: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine encounter shall not occur without your written consent, unless authorized under existing confidentiality laws.

    4. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine visit. All existing confidentiality protections under federal and Idaho State law apply to information disclosed during this telemedicine visit.

    5. Risks and Consequences: The telemedicine visit will be similar to a routine, in-person office visit, except technology will allow you to communicate with your provider at a distance. At first you may find it difficult or uncomfortable to communicate using video images. We recommend making you are in a quiet place with a strong internet or cellular data connection and are able to remain uninterrupted during the scheduled visit. The use of video technology to deliver healthcare and educational services is a newer technology and is being deployed rapidly during this national health crisis and may not be equivalent to direct in-person patient to provider contact.

    6. Rights: You may withhold or withdraw consent to the telemedicine visit at any time without affecting your right to further care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the option to consult with the provider in-person at the practice location. Telemedicine visits/consultations are elective and will only proceed with the patients signed consent of this document.

    7. Financial Agreement: This telemedicine visit will be billed to your medical insurance. Deductible, co-insurance, copays and non-covered amounts will apply and are your financial responsibility just as they are during an in-office, in-person visit.

    8. I have been advised of the potential risks, consequences, and benefits of telemedicine. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.


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