Telemedicine

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information to improve patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following: 

• Patient medical records 
• Medical images 
• Live two-way audio and video 
• Output data from medical devices and sound and video files 

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data. They will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. 

Expected Benefits:

• Increases access to care. Patients easily obtain medical services.
• Improves health outcomes, early detection, and treatment often improve outcomes.
• Improves patient engagement, telemedicine applications empower patients to play an active role in their healthcare.
• Telemedicine reduces travel time and related stresses.
• Convenience, allows patients to consult with a provider from virtually anywhere, whether it’s their home or the office.
• Decreases chances of catching an illness, by avoiding the risk of exposure or the possibility that you may pass your illness on to someone else.

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

• A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
• The potential to miss relevant signs and symptoms, which can lead to an inaccurate or incomplete diagnosis
• Information transmitted may not be adequate (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); 
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• Security protocols could fail, causing a breach of privacy of personal medical information; 
• There is a risk that information may be forwarded, intercepted, circulated, stored, or even changed, and the security of the devices used may be compromised.
• Family, friends, co-workers, employers, and hackers may have access to any technology, devices, or applications that you use.

 
By signing this form, I understand the following: 

1. I understand the laws that protect the privacy and confidentiality of medical information apply to telemedicine. In addition, no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my consent. 
2. I understand that I have the right to decline or withdraw my consent to the use of telemedicine services at any time, without affecting my right to future care or treatment. 
3. I understand that I have the right to inspect all information obtained and recorded during a telemedicine interaction, and may receive copies of this information for a reasonable fee. 
4. I understand that a variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. Priority Health Care’s staff has explained the alternatives to my satisfaction. 
5. I understand that it is my responsibility to communicate through a computer or device that I know is safe.
6. I understand that I must only use telemedicine services while physically located within the state of Louisiana. I cannot attempt to utilize telemedicine services when in another state or country.
7. I understand that telemedicine is for non-emergent situation. In case of emergency, I must proceed to the nearest emergency room or call 911. 
8. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but no results can be guaranteed or assured. 
9. I understand that for any additional services, I must contact Priority Health Care at 504-309-3262.

Payment for Telemedicine Services 
Priority Health Care will bill insurance(s) for telemedicine services when these services have been determined to be covered by an individual’s insurance plan. In an event the insurance does not cover telemedicine, the individual can pay out-of-pocket, or when there is no insurance coverage, a sliding fee scale discount is available.

Patient Consent to the Use of Telemedicine

(Parent/Legal Guardian/or Patient if over 18)
I have carefully read and understand the information provided regarding telemedicine, and all my questions have been answered to my satisfaction. I hereby give my informed consent to Priority Health Care’s provider to use telemedicine to diagnose and provide treatment.