Telemedicine Consent Form

TELEMEDICINE CONSENT

To better serve the needs of people throughout our region, some health care services are now available by two-way interactive video communications and by the electronic transmission of pertinent medical information that may assist in evaluating and treating medical conditions or services. This is referred to as “telemedicine” or “telehealth.”

Thank you for choosing us for your telehealth care. Patients are essential participants in health care, and we want you to understand your rights and responsibilities while receiving care from us. If you have any questions about this form, please ask your Provider.

I understand that I may be evaluated and treated by staff members or a provider from Cherry Creek Aesthetics DBA Weight Loss MD in Denver, Colorado, DTC Medical Weight Loss in Greenwood Village, Colorado, and Boulder Medical Weight Loss in Boulder, Colorado. The Provider at one of those sites is referred to as the “Telehealth Provider.” Since this may be different than the type of consultation or treatment with which I am familiar, I understand and agree with the following:

1. Consent for Telehealth Services: Telehealth involves the transmission of my video or digital photographs and/or details of my medical record, such as intake questionnaires and test results (collectively, “Transmitted Data”). All Transmitted Data is sent via secure electronic means to the Provider (s) to facilitate the consultation or medical service being performed. I understand that:
   • The Provider may be at a different location than me. A local health care provider may be at my place with me to assist in my consultation or treatment.
   • I will be informed of any other person present, seen or unseen, during the telehealth encounter other than myself, individuals accompanying me, or the Provider. I have the right to exclude anyone from either location.
   • All confidentiality protections required by law or regulation will apply to my care.
   • I have the right to refuse or stop participation in telehealth services at any time and request alternate services such as an in-person appointment. However, I understand that equivalent in-person services might not be available at the exact location or time as telehealth services.
   • I have the right to follow up with the Provider as necessary should I have further questions or concerns regarding the condition I consulted or was treated by telehealth means.
   • If an emergency occurs during a telehealth encounter at our clinic, the health care personnel at my location manage the emergency. Suppose an emergency occurs during a telehealth encounter when I am at a non-healthcare site. In that case, I should call 911 and stay on the audio or video connection (if applicable) until help arrives.
2. Records and Release Information: Transmitted Data may become part of my medical record. Transmitted Data will not be transferred to people outside my health care team except as described below and if I provide additional written consent.

• • I will have access to all the information in my medical record resulting from the telehealth services I would have for a similar in-person visit, as provided by federal and state law.
  • The Provider (s) may use or disclose my health information for treatment, continuity of care, payment, internal services, or when required by law or regulation in certain unique situations.
  • All information releases are subject to the same laws and regulations as in-person care.

I understand that providers at Weight Loss MD in Denver, Colorado, DTC Medical Weight Loss in Greenwood Village, Colorado, and Boulder Medical Weight Loss in Boulder, Colorado, may be subject to Colorado’s Governmental Immunity Act, which sets forth certain restrictions and limitations on liability for claims.