Introduction

Telemedicine involves the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. Telemedicine may be used for diagnosis, treatment, follow-up, and/or patient education, and may include, but is not limited to:

– The electronic transmission of medical records, photo images, personal health information or other data between a patient and a provider.

– Interactions between a patient and provider via audio, video, and/or data communications.

– Use of output data from medical devices, sound, and video files.

– The electronic systems used by MAO Inhibitors, Inc., will incorporate network and software security protocols to protect the privacy and security of health information and imaging data and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

The delivery of healthcare services via telemedicine is an evolving field, and that the use of telemedicine in my medical care and treatment may include uses of technology not specifically described in this consent.

Possible Benefits of Telemedicine Include:

– Telemedicine can be easier and more efficient for you to access medical care and treatment.

– You can obtain medical care and treatment at times that are convenient for you.

– You can interact with providers without the necessity of an in-office appointment.

Possible Risks of Telemedicine Include:

– Information transmitted to your provider(s) may not be sufficient to allow for appropriate decision making by the provider(s).

– Inability of your provider(s) to conduct certain tests, assess vital signs in-person, conduct an in-person physical exam, or fully visualize your body may in some cases prevent the provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.

– Inability of your provider to provide treatment for your particular condition via telemedicine and you may need to seek alternative care.

– Delays in medical evaluation/treatment could occur due to failures of the technology.

– Security protocols or safeguards could fail causing a breach of privacy.

– Given regulatory requirements in certain jurisdictions, your provider(s) treatment options, especially pertaining to certain prescriptions may be limited.

– Non-secure transmission of data. For example, if you choose to user a personal email such as Gmail or Yahoo Mail to send or receive communications.

Alternatives Include:

– In-person care. I can seek in-person help from my primary care provider. If I do not have a primary care provider, I can contact my insurance company to find one. If I do not have insurance, I can reach out to a Federally Qualified Health Center here: https://findahealthcenter.hrsa.gov/ which may be able to work with my budget.

By agreeing to this consent to telemedicine, I understand that:

1. My information is still protected under The Health Insurance Portability and Accountability Act (HIPAA).

2. 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 have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

4. A variety of alternative methods of medical care may be available to me, and that I may choose an alternative at any time.

5. 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.

6. It is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

7. The potential benefits and risks from the use of telemedicine, but that no results can be guaranteed or assured.