Telehealth Informed Consent

“Telehealth” means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Telehealth through Lackey Clinic involves the communication of my medical information both orally and visually to a health care provider at Lackey Clinic located in Virginia.

Risks and Benefits to Telehealth:

1. It is the role of my practitioner to determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter. Telehealth based services and care may not be as complete as face-to-face services. If my physician believes I would be better served by another form of services (for example face-to-face services) I will be referred to a physician who can provide such services in my area. Types of activities permitted using telehealth services include initial patient consultations, chronic care follow-up, select acute care visits, prescription refills, and patient education.
2. I may benefit from telehealth, but the results cannot be guaranteed or assured.
3. There are benefits, risks and alternatives involved with telehealth. Benefits include having access to medical care without having to travel outside of my local community. A potential risk of telehealth is because of my specific medical conditions, or due to technical problems, a face-to-face consultation still may be necessary after the telehealth appointment. Despite reasonable efforts on the part of my physician, the transmission of my medical information could be disrupted or distorted by technical failures. In rare circumstances, security protocols could fail causing a breach of patient privacy.

I have the following rights with respect to telehealth

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
2. The laws that protect the confidentiality of my medical information also apply to telehealth. The audiovisual information transmitted electronically will be encrypted during transmit and will not be stored. The dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my consent. The information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
3. I have a right to access my medical information and copies of my medical records in accordance with Virginia law.