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I understand that telemedicine is the remote evaluation and treatment of patients by means of telecommunications technology. After an initial in-person consultation, I may be eligible to receive telemedicine sessions if my Certus health care provider determines it could benefit me. I have the right to withhold or withdraw my consent for the use of telemedicine at any time. My Certus health care provider may also determine that my telemedicine sessions should be terminated in place of in-person care.

I understand how to use the telemedicine technology and equipment. In the case that the technology and/or equipment does not work during the session, then the session will be cancelled and rescheduled. However, some technology interruption is expected, and I understand it does not discount the fees of the session unless the session is terminated.

The laws that protect privacy and the confidentiality of medical information apply to telemedicine. Certus will also maintain a complete record of all telemedicine sessions just as they maintain records for in-person care.

I understand that other Certus staff may be present during the session to operate equipment. My Certus health care provider will inform me of the presence of any Certus staff in the session and I have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.

I may be prescribed medicine as a part of my telemedicine treatment. In accordance with State and Federal regulations, some medications may not be prescribed without an in-person physical examination or in-person care as determined by my Certus health care provider.

I understand there could be some benefit to telemedicine such as improved access to medical care, more efficient medical management, reduced transportation barriers, and improved continuity of care, among others. But I also accept the risks of telemedicine such as inadequate quality of the transmitted information necessitating future sessions, delays in medical evaluation and treatment due to deficiencies or failures of the equipment, and failures in security protocols.

I have read this document carefully and understand the risks and benefits of telemedicine and have had the opportunity to have my questions answered. By signing below, I certify that I have read and understand the terms stated in the Telemedicine Treatment Consent Form and that I give my consent to participate in telemedicine sessions.

Patient Name*
Guarantor Name
(if different than patient)
Patient signature required. If consenting as Guarantor, include signature below with patient's signature.
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