Informed Consent for Telehealth Services
Last Updated on July 12, 2020
The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
MDLink physicians and nurse practitioners (each a “provider” and collectively, our “providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
- Improved access to care by enabling you to remain in your home while the MDLink provider consults and obtains test results at distant/other sites.
- More efficient care evaluation and management.
- Obtaining expertise of a specialist as appropriate.
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
- In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact MDLink at firstname.lastname@example.org or call us at 876-537-8478.
- I hereby consent to receiving MDLink’s services via telehealth technologies. I understand that MDLink and its independently contracted providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the MDLink provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
- I understand that the MDLink provider will take responsibility for my care only after I have created an account, answered all the required health questions and provided a photo and/or have had a video chat and made payment, and the MDLink provider has subsequently received my request for treatment and my responses to all the required health questions and any photos and/or information received from a video chat, reviewed all my information, and then subsequently determined that I am a good candidate for the telehealth services. I understand that the provider’s duty of care does not begin at the point of me answering questions or making payment or starting a video visit but at the point at which the doctor accepts the duty of care.
- I understand that making a request for treatment (by completing a visit in the mobile app or website and making payment, including providing photos and/or initiating a video chat) or sending a message through the mobile app or website or sending an email does not in and of itself create a duty of care or create a doctor-patient relationship.
- I understand that national law requires health care providers to protect the privacy and the security of health information. I understand that MDLink will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of country.
- I understand there is a risk of technical failures during the telehealth encounter beyond the control of MDLink. I agree to hold harmless MDLink for delays in evaluation or for information lost due to such technical failures.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 1-1-9 immediately and that the MDLink providers are not able to connect me directly to any local emergency services.
- I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the MDLink provider (e.g. labs or bloodwork).
- I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the MDLink provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
- I understand that I will not be prescribed any narcotics for pain, nor is there any guarantee that I will be given a prescription at all.
- I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
If there is an emergency situation telemedicine is not an appropriate method of care.
IN CASE OF AN EMERGENCY, YOU SHOULD SEEK IMMEDIATE MEDICAL ATTENTION OR EMERGENCY CARE BY CALLING 119.
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PROVIDER, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS OR DAMAGE, INCLUDING ANY AND ALL INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, EXPENSES, LIABILITIES, CLAIMS, OR DEMANDS WHATSOEVER ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PROVIDER'S NEGLIGENCE.