The purpose of this form is to obtain your consent to participate in a tele-health consultation.

Purpose and Benefits. The purpose of the tele-health consultation is to increase access to medical care by specialists to patients.

Nature of Telemedicine Consultation. During the tele-health consultation:

a. Details of you and/or your child’s medical history, behavioral assessments, and treatment, may be discussed through the use of interactive video, audio and telecommunications technology.
b. Participation from you or your child may be necessary.
c. Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.

Medical Information and Records. All existing laws regarding your access to medical information and copies of your medical records apply to this tele-health consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws.

Confidentiality. Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and Michigan State law apply to information disclosed during this telemedicine consultation.

Risks and Consequences. The tele-health consultation will be similar to a routine office visit, except interactive video technology will allow you to communicate with a clinician at a distance. At first you may find it difficult or uncomfortable to communicate using video images. The use of video technology to deliver healthcare and educational services is a new technology and may not be equivalent to direct patient to clinician contact.

Rights. You may withhold or withdraw consent to the tele-health consultation at any time without affecting your right of future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. You have the option to consult with the specialist in person if you travel to his or her location.

I have been advised of all the potential risks, consequences and benefits of telemedicine. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.

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