By signing this document, I certify that:

  1. I understand that my health care provider at Green Spirit Clinic, PLLC, wishes me to engage in a telemedicine consultation.

  2. I understand that “telemedicine” means the use of an electronic media to link patients with health care professionals in different locations.  To be considered telemedicine, the health care professional must be able to examine the patient via a real-time, interactive audio or video telecommunication system, and the patient must be able to interact with the off-site health care professional at the time the services are provided.

  3. My health care provider explained to me how the audio or video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

  4. I understand that a telemedicine consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  5. I understand there are potential risks to this technology, including interruption, unauthorized access, and technical difficulties.  I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the audio/video conferencing connections are not adequate for the situation.

  6. I understand that telemedicine is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

  7. I understand that the laws that protect privacy and the confidentiality of medical information (HIPAA) also apply to telemedicine.

  8. To maintain confidentiality, I will not share my appointment link or let anyone listen in who is unauthorized to attend the appointment.

  9. 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.

  10. I have read this form and/or had this form explained to me, and I fully understand its contents.

  11. I have been given ample opportunity to ask questions.  My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

  12. I understand that by signing this form I am consenting to receive health care services via telemedicine.


Your Signature

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