CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATIONS WITH MIMPC
I am giving consent to engage in telemedicine consultations with MIMPC for the sake of medical counsel, medical education, specialist referrals, laboratory orders medication refills, and assessment, diagnosis and treatment of minor, non-
I understand that this consultation will not be the same as a direct patient/health care provider visit due the fact that I will not be in the same room as my health care provider. I have been counseled that as a result of the lack of proximity, my provider will not have certain advantages in the assessment of my health care that he or she would have if he or she were present in the same room with me.
I understand that my telemedicine provider may exercise the professionalism to refuse to treat certain medical ailments which they may determine require further analyses to make a sound medical decision.
I understand that there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider(s) or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are somehow compromised or not adequate for the situation.
I understand that according the privacy information that is also made available to me on the MIMPC website and as part of my mandatory education materials, my health care information may be shared with other authorized individuals. Rarely, others may be asked to join the video conference other than my health provider who may be involved in the promotion of my health or who are present to assist with operating the video equipment. I am informed that these people will all maintain confidentiality of any information obtained. I further understand that I will be informed of their presence and purpose in the consultation and thus will have the right to request the following:
Omit specific details of my medical history/physical examination that are personally sensitive to me
Terminate the consultation at any time
In the event of a medical emergency during a telemedicine visit, I understand that my telemedicine provider will attempt to assist me as best as possible, but only until 911 is able to dispatch emergency personnel to my location. I WILL NOT under any circumstances knowingly use a telemedicine visit with any MIMPC provider to address any medical emergency either for myself or another person at any time. It has been explained to me on the MIMPC website what constitutes a medical emergency and what conditions and uses are appropriate for telemedicine consult. I hereby affirm my understanding of this explanation.
I agree to be in the same state where my MIMPC provider is licensed at the time of my telemedicine visit. I will not knowingly give false information about my physical location at the time of my virtual visit.
I understand that health insurance may not be accepted for this form of consultation. I am, therefore, responsible at all times for the financial settlement of my services. Unless otherwise explicitly directed, the payment for my telemedicine consultation with any MIMPC provider is accepted in cash, PayPal, or credit card and is required in advance prior to consultation. I understand that the consultation will not commence until the payment is settled in full.
I have read this document carefully, and understand the risks and benefits of the telemedicine consultation. I have had all my questions regarding this technology explained to me and I hereby give consent to participate in telemedicine visits with MIMPC under the terms described herein.