Reliant.MD Informed Consent for Evaluation and Treatment

Telemedicine is the remote delivery of healthcare services, such as clinical and diagnostic assessments, over a telecommunication infrastructure such as phones, tablets, and computers. Providers may include physicians, nurse practitioners, or physician assistants. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

Tele-electronic systems used 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.

The acute services rendered by our telemedicine platform does not replace the relationship you have with your primary care or specialist providers, and the day to day responsibility for your patient care should remain with the your local clinician, if you have one, as does your longitudinal medical record.

Expected Benefits

Possible Risks

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
  2. 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.
  3. I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation.
  4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
  5. 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.

Patient Consent To The Use of Telemedicine

I have read and understand the information provided above regarding telemedicine.

I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.

By checking the Box labeled “I certify that I have read and accept the terms of Reliant.MD’s Informed Consent” I hereby state that I have read, understood, and agree to the terms of this document.

By checking the Box containing “Consent to retrieve medication history” you are allowing us to import your medication history list.