The purpose of this form is to obtain your consent for a telehealth visit with dermatology providers (“Provider”) at Vanguard Skin Specialists. The purpose of this visit is to help in the care of your skin problem.

1. 1. How Telehealth Works. In a telehealth visit, you will interact in real time with your Provider via secure, online videoconferencing technology. Alternatively, the Provider may give you the option of submitting a photo and chief complaint (the reason for your visit) via secure electronic messaging. Your Provider has the right to discontinue or not provide a consult via videoconference or secure electronic messaging should the videoconference connection or the forwarded image be of poor quality. You may be required to make an in-person appointment for further evaluation should this occur. The Provider will look at the patient’s skin during a videoconference or review the photos you submitted. The Provider will then give you advice about your dermatologic condition and how to treat and take care of your condition. The information from the Provider may not be the same as a face-to-face visit because the Provider is not in the same room.
   2. Pros, Cons and Your Options. With telehealth, a Provider will advise you based on viewing your condition during a videoconference or based on the photos that were submitted electronically. Sometimes a face-to-face follow-up visit with the Provider may still be needed. If you do not come into the office for an in-person visit, the Provider’s advice will be solely based on the viewing of your skin condition during a videoconference or on the information and images provided by you electronically. In the absence of an in-person physical evaluation, the Provider may not be aware of certain facts that may limit or affect his or her assessment or diagnosis of your condition and recommended treatment. It is possible that there will be errors or deficiencies in the transmission of the images of your skin condition during the videoconference or in the photos submitted electronically that may impede the Provider’s ability to advise you about your condition, Also, very rarely, security measures can fail to protect your personal information, but the company that is providing the telehealth visit has extensive security measures in place to prevent such failures from happening
   3. Presence of Others During Your Telehealth Visit. People other than your Provider may be a part of the patient’s care and present during a telehealth visit. Anyone that is part of the telehealth team will be supervised by your Provider, and the final recommendations about your care will come from your Provider. Also, non-medical people may help to set up the telehealth equipment. You may ask for persons other than your Provider to leave the room if you are uncomfortable having them participate in your telehealth visit.
   4. Medical Information and Records. All federal and state laws covering access to your medical records (and copies of medical records) also apply to telehealth. No one other than the health care team described above can view your photos or information unless you agree to give them access.
   5. No Recording Visits. Vanguard Skin Specialists does not record telehealth visits that are conducted via videoconference or phone. You agree that you will also not record the telehealth visits.
   6. Privacy: All information given at your telehealth visit will be maintained by the doctors, other health care Providers, and health care facilities involved in your care and will be protected by federal and state privacy laws.
   7. Your Rights. You may opt out of the telehealth visit at any time. This will not change your right to future care or health benefits.
   8. Waiver/Release. You understand and agree that you solely assume the risk of any errors or deficiencies in the electronic transmission of information during your telehealth visit or in the electronic submission of your images to your Provider and further understand that no warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis. To the extent permitted by law, you also agree to waive and release your Provider and his or her institution or practice from any claims you may have about this advice or the telehealth visit generally. The consent provided in writing or verbally will expire in one year from the date of agreement, but your waiver and release shall apply indefinitely for any telehealth visits that occur during the one-year period after your signature date.

I have had the chance to ask questions and all of my questions have been answered. I have read this form, understand the risks and benefits of the telehealth visit, and agree to telehealth visit under the terms explained above.