Informed Consent for TeleMedicine Services

Patient Name: ______________________   Date of Birth: _____________

Location of Patient: ___________________________________________

Name of Practitioner:__________________________________________

Location of Practitioner: ________________________________________

Date / Time Consent was obtained: ________________________________

Written Signature: _______________________Check if Verbal: _________

You understand that TeleMedicine is the use of electronic information and communication technologies by a health care practitioner to deliver services to an individual when he / she is located at a different site than the practitioner; and hereby consent Greater Rochester Internal Medicine providing health care services to you via TeleMedicine.

You understand that the laws that protect privacy and confidentiality of medical information also apply to TeleMedicine. As always, your insurance carrier will have access to your medical records for quality review / audit just like when you are seen in the office setting.

You understand that you will be responsible for any copayments, coinsurance, deductibles that apply to your visit, just like when you are seen in the office setting.

You understand that you have the right to withhold or withdraw your consent to the use of TeleMedicine during your care at any time, without effecting your right to future care or treatment. You may revoke your consent orally or in writing at any time by contacting our office at 585-865-1110 ext. 201. As long as this consent is in force (has not been revoked) Greater Rochester Internal Medicine may provide health care services to you via TeleMedicine without need for me to verbally complete another consent form.