TELEMEDICINE MEMBER CONSENT FORM

Purpose

The purpose of this form is to obtain your consent to participate in a telemedicine consultation in connection with the following procedure(s) and/or service(s):

Medication Management, send and receive documents electronically, counseling, skills training and all CORE services to maintain my mental health.

Nature of Telemedicine Consult

• Details of your medical history, examinations, x-rays, and tests will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology.

• A physical examination of you may take place.

• A non-medical technician may be present in the telemedicine studio to aid in the video transmission.

• Video, audio, and/or photo recordings may be taken of you during the procedure(s) or service(s).

Medical Information & Records

All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation.
Please note that not all telecommunications are recorded and stored.
Dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent.

Confidentiality

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation.
All existing confidentiality protections under federal and Georgia state law apply to information disclosed during this telemedicine consultation.

Rights

You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment,
or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

Disputes

You agree that any dispute arising from the telemedicine consultation will be resolved in the State of Georgia,
and that Georgia law shall apply to all disputes.

Risks, Consequences & Benefits

You have been advised of all potential risks, consequences, and benefits of telemedicine.
Your healthcare practitioner has discussed with you the information provided above.
You have had the opportunity to ask questions, and all questions have been answered to your satisfaction.
You understand the information provided on this form and agree to participate in a telemedicine consultation for the described procedures/services.

Agreement

I agree to participate in a telemedicine consultation for the procedure(s) described above.

Additional Information

Page 1 of 2 (Revised 1/1/2020)