DEFINITION OF TELEHEALTH: Telehealth is a type of medical service provided by a healthcare provider who is not physically present with the patient. The healthcare provider instead communicates and interacts with the patient through phone, video, and/or email to attempt to diagnose and treat non-emergent medical conditions by obtaining individual patient medical information. The information obtained may be used for therapy, diagnosis, follow-up and/or education, and may include any combination of the following: Live two-way audio and/or video, medical images, patient medical records, interactive audio, and sound and video files. Telehealth is an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care remains with a primary care physician in person.

Expected Benefits: Access to medical professionals and medical care may be improved by allowing you to remain in your current location(i.e. home, work, school) while the healthcare provider consults from another location; improved efficiency of medical evaluation and management; obtaining expertise of a healthcare provider in a more timely manner.

Possible Risks: Security risks allowing breach of privacy of personal medical information; lack of physical exam leading to medical errors; delays in medical evaluation and treatment leading to adverse health risks; inadequate video/audio leading to need to be seen by a doctor in person; reduced access to complete medical records/history/exam leading to drug interactions, judgement errors, or allergic reactions.

I agree to participate in a consultation using TX Telehealth, PLLC and agree to receive services via telehealth. I confirm that I am of sound mind and can make appropriate medical decisions. If I am consenting on behalf of a minor, incapacitated, or otherwise legally dependent patient, I certify that I have legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.

I agree that I am 18 years or older. I understand that no one under the age of 18 can have a consultation without a parent or guardian’s consent and that parent or guardian must be present during the entire telehealth visit.

I authorize the electronic transmission of my/the patient’s medical information and/or videoconference session so that it can be viewed by a healthcare provider and other persons involved in my/the patient’s medical care.

I understand that I can withdraw my consent at any time by ending the telehealth session and my right to future telehealth consultations will not be affected. I should immediately pursue a face-to-face consultation with another medical provider.

I understand that I/the patient will not be in the same location or room as the medical provider and that all interactions with the medical provider will be through phone, electronic messaging, and/or video. I understand the inability to have direct, physical contact with a medical provider and inability to perform any diagnostic testing (such as blood, urine, other lab, and imaging tests) may result in adverse drug interactions, allergic reactions, incorrect diagnosis, or other judgement errors.

I understand there is no guarantee that this telehealth session will eliminate the need for me/the patient to see a primary care physician, emergency physician, or specialty physician in person. I understand in some instances the medical provider providing telehealth consultation may deem it necessary for me/the patient to be evaluated by an in-person physician.

I understand the potential risks of telehealth which may include delays in evaluation, delays in treatment, and medical errors due to technical difficulties, distortion of images, unauthorized access, lack of in-person physical exam, and lack of access to complete medical information.

I agree to report my/the patient’s location accurately to the medical provider and acknowledge I/the patient must be in the state of Texas at time of consultation.

I understand that TX Telehealth, PLLC providers will not prescribe controlled medications such as opioids, benzodiazepines, ADHD stimulants, etc.

I understand that controlled medications will not be prescribed, nor is there any guarantee that I will be given a prescription at all.

I understand TX Telehealth, PLLC does not provide evaluation or treatment for life or limb threatening emergencies. If you think you or the patient is having a medical emergency, you must immediately call 911 or go to the nearest emergency department.

By scheduling and continuing with a Telehealth appointment I am agreeing that:

I have read this document carefully, read it in full, and understand the risk and benefits of a telehealth consultation. I have had my questions regarding telehealth explained and I hereby give my informed consent to participate in a telehealth consultation.