Informed Consent for Telemedicine Services
Last updated on September 5, 2020
Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telemedicine services offered by MedCare Clinic Aruba/Sint Maarten (“MedCare Clinic Sint Maarten” is part of “MedCare Clinic Aruba” but the entity will hereafter be referred to as “MedCare Clinic”) may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.
The electronic communication systems we use 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.
MedCare Clinic providers include any and all healthcare providers who are assigned to your telemedicine appointment.
MedCare Clinic providers are an addition to, and not a replacement for, your local family doctor/primary care physician. Responsibility for your overall medical care should remain with your local family doctor/primary care physician.
– Improved access to care by enabling you to remain in your home/whichever environment you prefer while MedCare Clinic providers consult and obtain test results at distant/other sites.
– More efficient care evaluation and management.
– Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
– In rare events, MedCare Clinic providers may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telemedicine consult, a meeting with your local family doctor/primary care physician, or something else.
– In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
– In rare events, a lack of access to complete medical records may result in adverse interactions or allergic reactions or other judgment errors.
If you need to contact us for whatever reason, please reach us at firstname.lastname@example.org or call us at +297 280 0630.
By clicking “I have read, understood, and agree with the Informed Consent for Telemedicine Services,” you acknowledge that you understand and agree with the following:
1. If your health insurance coverage does not pay for the services you receive from MedCare Clinic in full, you may be fully or partially responsible for payment.
2. I hereby consent to receiving MedCare Clinic’s telemedicine services via the technologies it has available. I understand that MedCare Clinic and its providers offer telemedicine-based medical services, but that these services do not replace the relationship between me and my local family doctor/primary care doctor. I also understand it is up to the MedCare Clinic provider to determine whether or not my specific clinical needs are appropriate for a telemedicine encounter.
3. I understand that the MedCare Clinic provider will take responsibility for my care only after I have answered all the required health questions, made payment, and/or had an audio/video call with the MedCare Clinic provider and the MedCare Clinic provider has subsequently received my request for treatment and my responses to all the required health questions and any photos and/or information received from an audio/video chat, reviewed all my information, and then subsequently determined that I am a good candidate for the telemedicine services. I understand that the provider’s duty of care does not begin at the point of me answering questions or making payment or starting an audio/video call but at the point at which the provider accepts the duty of care.
4. I understand that making a request for treatment (by completing a telemedicine appointment and making payment, including providing photos and/or initiating an audio/video chat) or sending a message through the website or through other means does not in and of itself create a duty of care or create a provider-patient relationship.
5. I understand that MedCare Clinic will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telemedicine may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of the Dutch Caribbean islands.
6. I understand there is a risk of technical failures during the telemedicine encounter beyond the control of MedCare Clinic. I agree to hold harmless MedCare Clinic for delays in evaluation or for information lost due to such technical failures.
7. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine services in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telemedicine services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to contact my local healthcare provider immediately and that MedCare Clinic providers are not able to connect me directly to any local emergency services.
8. I understand that alternatives to telemedicine consultation, such as in-person services are available to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the MedCare Clinic provider (e.g. labs or bloodwork).
9. I understand that I may expect the anticipated benefits from the use of telemedicine in my care but that no results can be guaranteed or assured.
10. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the MedCare Clinic provider in order to operate the telemedicine technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination; and/or (3) terminate the consultation at any time.
11. I understand that there is no guarantee that I will be given a prescription at all.
12. I understand that if I participate in a telemedicine consultation that I have the right to request a copy of my medical records which will be provided to me by MedCare Clinic at reasonable cost of preparation, shipping, and delivery.
If there is an emergency situation telemedicine is not an appropriate method of care.
IN CASE OF AN EMERGENCY, YOU SHOULD CONTACT YOUR LOCAL HEALTHCARE PROVIDER.
YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PROVIDER, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS OR DAMAGE, INCLUDING ANY AND ALL INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, OR EXEMPLARY DAMAGES, EXPENSES, LIABILITIES, CLAIMS, OR DEMANDS WHATSOEVER ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PROVIDER’S NEGLIGENCE.
Credit for our Informed Consent for Telemedicine Services
We have modified and repurposed HeyDoctor.com’s Informed Consent for Telemedicine Services for our use.