Telehealth Consent

I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

By acknowledging my consent below, I understand and agree to the following:

1. I understand that Allermi Medical Associates, P.C. (“Allermi Medical Associates”) provides Telehealth consultations, which are conducted through store-and-forward or videoconferencing technology, and my healthcare provider will not be present in the room with me.

2. I understand there are potential risks to the use of Telehealth technology, including but not limited to interruptions, delays, unauthorized access, and/or other technical difficulties. I understand that either my healthcare provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit.

3. I understand that I could seek an in-office physician visit rather than obtain care from Allermi Medical Associates, and I am choosing to participate in a Telehealth consultation.

4. I understand that my healthcare information may be shared with others for scheduling or billing purposes.

5. In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room.

6. I understand that my unauthorized recording (audio, video, still photography, etc.) of my Telehealth visit with an Allermi Medical Associates provider is strictly prohibited.

7. I understand that I am responsible for providing Allermi Medical Associates with any updates to my medical history, including surgeries, changes to medication, or new diagnoses. I agree to notify Allermi Medical Associates if any significant changes occur during the course of my subscription and to respond to requests for updates as necessary.

By acknowledging below, I certify:

-That I have read this form and/or had it explained to me
-That I understand the risks and benefits of a Telehealth appointment 
-That I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction