Telemedicine Informed Consent Form

  • Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
    • I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
    • I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
    • I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
      • If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
    • I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
      • I may revoke my right at any time by contacting The Heartbeat Clinic at 214-504-9942.
    • I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
    • I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
      • I understand that my insurance carrier will have access to my medical records for quality review/audit.
      • I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.
      • I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.
    • I understand that this document will become a part of my medical record.
  • By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).
  • Patient/Parent/Guardian Signature
  • Witness Signature
  • MM slash DD slash YYYY