Video Consultation – New Patient

Insurance

Consent Form

By submitting this form, I understand and agree to the following:

• The laws that protect the privacy and confidentiality of medical information also apply to Telemedicine.
• I have the right to withhold or withdraw my consent to the use of Telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
• In some instances, a follow-up physical consultation and/or referral for diagnostic testing for further evaluation may be recommended.
• I understand that technical difficulties may occur before or during the Telemedicine sessions that may impact the quality of my appointment
• I accept that the professionals can conduct interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
• I understand that my current insurance may not cover the additional fees of the Telemedicine practices and I may be responsible for any fee that my insurance company does not cover.
• I agree that my medical records on Telemedicine can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

Patient Consent To The Use of Telemedicine

I have read and understand the information provided above regarding Telemedicine. I hereby give my informed consent for the use of Telemedicine in my medical care.

I hereby consent to and authorize Cardiovascular Associates Limited to use Telemedicine in the course of my diagnosis and treatment.