INFORMED CONSENT FOR TELEMEDICINE SERVICES

DMV Medical Group, LLC

P: 240-669-7496

F: 301-321-7800

Website: www.dmvmedgroup.com

INTRODUCTION

Telemedicine involves the use of electronic communication technologies to facilitate healthcare services between healthcare providers and patients at different locations. This may include the exchange of medical information to improve patient care, diagnosis, therapy, follow-up, and education.

Telemedicine services may involve the use of:

  • Patient medical records

  • Medical images

  • Live two-way audio and video communication

  • Output data from medical devices, sound, and video files

Electronic systems used in telemedicine incorporate network and software security protocols to protect the confidentiality of patient identification and medical data. These measures safeguard information against unauthorized access, intentional corruption, or unintentional loss.

EXPECTED BENEFITS

  • Improved access to medical care by allowing patients to consult with healthcare providers from remote locations.

  • More efficient medical evaluation and management through rapid communication and information sharing.

  • Access to specialized medical expertise that may not be available locally.

POSSIBLE RISKS

While telemedicine is a safe and effective method of healthcare delivery, there are potential risks, including but not limited to:

  • In rare cases, technical issues such as poor image resolution or audio quality may limit the provider’s ability to make accurate medical decisions.

  • Equipment malfunctions or connectivity issues may result in delays in evaluation and treatment.

  • Although rare, security protocols could fail, leading to a potential breach of privacy.

  • Limited access to complete medical records may result in adverse drug interactions, allergic reactions, or treatment errors.

PATIENT ATTESTATION & UNDERSTANDING

By signing this form, I acknowledge and understand the following:

  1. Confidentiality & Privacy: The laws protecting the privacy and confidentiality of medical information apply to telemedicine.

  2. No information obtained during a telemedicine consultation will be disclosed to researchers or third parties without my written consent.

  3. Right to Withdraw Consent: I have the right to withhold or withdraw my consent to telemedicine services at any time without affecting my right to future care or treatment.

  4. Access to Records: I have the right to inspect and obtain copies of my medical information obtained through telemedicine.

  5. I understand that a reasonable fee may apply for printed copies of my records.

  6. Alternative Treatment Options: I understand that telemedicine is one of several available healthcare options.

  7. My healthcare provider has explained alternative options to my satisfaction, and I may choose an alternative method at any time.

  8. Electronic Transmission of Information: My personal medical information may be electronically communicated to other medical practitioners who may be located in different areas, including out-of-state providers.

  9. Obligation to Inform Providers: I understand that it is my duty to inform my provider about any other electronic interactions regarding my care that I have had with other healthcare professionals.

  10. No Guarantee of Results: While telemedicine is expected to provide benefits, no specific results can be guaranteed.

  11. Location Requirement: I attest that I am located in the state of that insurance is registered during all telehealth encounters with DMV Medical Group providers.

PATIENT CONSENT TO TELEMEDICINE SERVICES

I have read and understand the information provided above regarding telemedicine. I have discussed it with my provider or a designated assistant, and all of my questions have been answered to my satisfaction.

I acknowledge that:

  • A copy of this consent form will be available for me to print.

  • I voluntarily consent to the use of telemedicine in my diagnosis, treatment, and ongoing medical care.