Introduction

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

• Improved access to medical care by enabling a patient to remain in his/her home / primary health care clinic while the physician obtains test results and consults from a distant/other sites.
• More efficient medical evaluation and management
• Obtaining expertise of a distant specialist.

Possible 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, information transmitted may not be sufficient to allow for appropriate medical decision;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of equipment;
• In very rare instances, 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 the following

• I understand that the laws that protect privacy and the 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 consent.
• 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 understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
• I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.

Patient Consent To The Use of Telemedicine

• I certify that the information given by me is true to the best of my knowledge and belief.
• I undertake the responsibility of informing of any change in the information at any time in the future.
• I hereby give my consent for the provision of healthcare and related services to me /and my dependent members by . The services may be provided in my home or in the clinic. I will indicate where the service is required.
• The information given here is confidential but may be divulged in case of any medico-legal requirements/research/caregiving.
• I hereby give my consent for storing my data and for teleconsultation with doctors on the telemedicine platform being utilized by . I am aware of the benefits and risks of telemedicine and I accept the same. For this I have read the detailed information on telemedicine that is provided
• I agree to pay for services utilized for myself/and for my dependent members promptly as per the rates decided by . I also authorize my family members or NOK to pay on my behalf.
• I agree that these services may be discontinued if I do not comply with standard medical and administrative requirements.
• I understand that provides primary healthcare and support services. It is not an Emergency Care Services. Any care in an emergency would be limited to basic first aid by a nurse till patient is evacuated. This would be viewed as a Good Samaritan Service

I have read and understand the information provided above regarding telemedicine 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.