Introduction
Telemedicine is the delivery of health care services when the health care provider and patient are not in the same physical location through the use of technology. Providers may include primary care practitioners, specialists, and or sub specialists electronically transmitted information may be used for diagnosis, therapy, follow up and / or patient education and may include any of the following:
• Patient medical records
• Medical images
• Interactive audio, video, and / or data communications
• Output data from medical devices and sound and video files
The interactive electronic systems will incorporate network and software security protocols to protect the confidentiality of a patient identification and imaging data and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
Potential Benefits
• Improved access to medical care by enabling a patient to remain in his or her local health care site for example their home, while the physician consultant obtains test results at distance slash other sites
• More efficient medical evaluation and management
• Obtaining expertise of a specialist
Potential Risks
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include but may not be limited to:
• In rare cases the provider may determine that the transmitted information is of inadequate quality thus necessitating a face to face meeting with the patient, or at least a rescheduled video consult.
• The consulting provider is not able to provide medical treatment to the patient through the use of telemedicine equipment nor provide for or arrange any emergency care that I may require.
• Delays in medical evaluation and treatment could occur due to the deficiencies or failures of equipment.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• In rare cases a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
By signing this form, I understand and agree to the following:
• I understand that the laws that protect privacy and confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
• I understand that I have the right to withhold or withdraw my consent or to use of telemedicine in course of my care at any time, without affecting my right to future care or treatment.
• I understand the alternatives to telemedicine consultation as they have been explained to me and in choosing to participate in a telemedicine consultation I understand that some parts of the exam involving physical tests may can be conducted by individuals at my location, or at a testing facility, and at the direction of consulting health care provider.
• I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state
• I understand that I may expect anticipated benefits from the use of telemedicine in my care but that no results can be guaranteed nor assured
• I understand that my health care information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in consultation and thus will have the right to request the following:
o Omit specific details of my medical history slash physical examination that are personally sensitive to me
o Ask non medical personnel to leave the telemedicine examination room: and / or
o Terminate the consultation at any time.
Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, and have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
I hereby give my informed consent for the use of telemedicine in my medical care.
CONSENT TO TREAT A MINOR CHILD
I hereby authorize EMC SERVICES OF SOUTH FLORIDA LLC, and whomever they may designate as their assistants or independent contractors, to evaluate and administer treatment as they deem necessary to my son / daughter / minor under my guardianship
I have read, signed, and fully understand EMC SERVICES OF SOUTH FLORIDA LLC assignment of benefits and all other required paperwork pertaining to the evaluation and treatment of my child. I herby as parent / legal guardian agree with the assignment of benefits and authorize EMC SERVICES OF SOUTH FLORIDA LLC to receive and utilize full benefits and rights that will be transferred to EMC SERVICES OF SOUTH FLORIDA LLC through the assignment of benefits. In addition, I agree as parent / legal guardian to be bound by all conditions of the assignment of benefits.
FINANCIAL AGREEMENT AND ASSIGNMENT OF INSURANCE BENEFITS
By way of original or copy hereof, I, understand, agree to pay for all services rendered to me by EMC SERVICES OF FLORIDA, Inc understand that as a courtesy to its patients providing insurance/billing information, EMC SERVICES OF FLORIDA, Inc will submit claims to my health care plan or insurance company. However, I further understand that I am responsible for payment of balance owed. I agree that I am also responsible for any deductibles, co-pays/co-insurance, charges for non-covered services, charges for services deemed “Medically Unnecessary” or charges for white I have not obtained a properly authorized written referral, (if required by my health plan). In the event I am not currently enrolled as a member of a health care plan, I understand I am responsible for all charges incurred at EMC SERVICES OF FLORIDA, Inc., should my account be referred to a collections agency and/or attorney for collections. I (or the undersigned) shall pay an initiation fee of $30.00 and assume all cost of collection, including but not limited to Court costs, Interest and Legal fees. I assume full responsibility for any returned checks written by me to EMC SERVICES OF FLORIDA, Inc., and agree to pay a $25.00 fee for this infraction.
ASSIGNMENT OF BENEFITS, I hereby assign to, EMC SERVICES OF FLORIDA Inc., all insurance benefit payments due to EMC SERVICES OF FLORIDA, Inc. I understand that regardless of this assignment, I remain primarily responsible to EMC SERVICES OF FLORIDA, Inc., for payment of all actual charges incurred. A photocopy of this assignment shall be as valid as the original.
RELEASE OF INFORMATION, I authorize EMC SERVICES OF FLORIDA, Inc. to disclose all or any part of my medical records to any insurance carrier, person or corporation, which is or may be liable under contract to EMC SERVICES OF FLORIDA, Inc. or to me or a family or employer of mine, for all or part of EMC SERVICES OF FLORIDA Inc. charges. This authorization includes, but is not limited to worker’s compensation carriers, commercial insurance carriers, and the fiscal intermediary under Medicare and Medicaid.
NOTICE OF INSURED’S RIGHTS: Billing requirements: Florida statues provide that with respect to any treatment or services, other than hospital and emergency services, the statement of charges furnished to the insurer by the provider may not include, and the insurer party are not required to pay charges for treatment of services rendered more than 30 days before the postmarked date of the statement, except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after the first examination or treatment of the claimant, the statement may include charges for treatment of services rendered up to, but not more than 60 days before the postmarked date of the statement.
PATIENT CONSENT, Based on physician’s referral for EMC SERVICES OF FLORIDA, Inc., services, I request and give consent to EMC SERVICES OF FLORIDA, Inc., its physicians and staff, to provide diagnostic and radiology services, contrast administration and related care. This includes treatment of any life-threatening condition that may arise during the course of my EMC SERVICES OF FLORIDA, Inc., examination(s) or while present at EMC SERVICES OF FLORIDA, Inc.
FOR MEDICARE PATIENTS ONLY
MEDICARE AUTHORIZATION, I request that payment of authorized Medicare benefits to be on my behalf to EMC SERVICES OF FLORIDA, Inc. for any services furnished by EMC SERVICES OF FLORIDA, Inc. I authorize any medical information to be released to any insurance carrier or to the Health Care Financing Administration and its agents, information needed to these benefits or any benefits determined for related services. I permit a copy of this authorization to be used in place of the original. I understand I am responsible for the Medicare Part B deductible and the remaining 20% of charges.
My signature below acknowledges that I have been given the opportunity to read or have had the above information explained to me and I fully understand the statement in this document and consent to each of them. I certify I am the patient or am duly authorized by the patient to execute the above and accept the terms.
