I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to the health care provider providing health care services to me via telemedicine.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. You and your health care provider will have access to your medical records for quality review/audit. Such information can be accessed by your insurance carrier upon request.
I understand that I will be responsible for any payments or co-insurances that apply to my telemedicine visit.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting the grievance officer. As long as this consent is in force (has not been revoked) Namaste Doctor may provide health care services to me via telemedicine without the need for me to sign another consent form.
I, the undersigned patient or the parent/legal guardian of the minor patient, agree to receive health care services from Namaste Doctor. I understand that the licensed health care practitioner, is located at another location (distant site) and consultation will happen by using special audiovisual equipment.
I, for myself or as the parent/legal guardian of the minor patient, also understand and agree that:
- I can decline the telehealth service at any time without affecting my right to future care or treatment, any program benefits to which I would otherwise be entitled cannot be taken away.
- I may have to travel to see a licensed health care practitioner in-person if I decline the telehealth service.
- If I decline the telehealth services, the other options and alternatives available to me, including in-person services, are up to my discretion.
- The same confidentiality protections that apply to my other medical care also apply to the telehealth service.
- I will have access to all medical information resulting from the telehealth service as provided by law.
- The information from the telehealth service (images that can be identified as mine or other medical information from the telehealth service) cannot be released to researchers or anyone else without my additional written consent.
- I will be informed of any individuals who will be presented at the originating site and the distant site during my telehealth service.
- I may exclude anyone from any site during my telehealth service, but acknowledge that if I choose to exclude the health care practitioner from my telehealth service, Namaste Doctor may terminate the doctor-patient or provider-patient relationship in time.
- I may see an appropriately trained staff person or employee in-person immediately after the telehealth service if an urgent need arises or I will be told ahead of time that this is not available.
I have read this document carefully, and my questions have been answered to my satisfaction.
Cancellation and Refund Policy
- Cancellations made 2 days or more in advance of the appointment date, will receive a 100% refund. Cancellations made within 1 – 2 days will incur a 50% fee of your consultation.
- Cancellations made within 1 day will incur a 100% fee of your consultation.