Telemedicine and Remote Patient Monitoring Informed Consent

Thank you for choosing Texas TeleHealth! You are viewing this form because you have elected to engage in telemedicine visits and/or remote patient monitoring (“RPM”) services with a Texas TeleHealth healthcare practitioner. Your practitioner is Christopher Litchfield MD, a clinician licensed in Texas.

IF YOU DO NOT UNDERSTAND OR AGREE TO ANY OR ALL OF THE ITEMS BELOW, PLEASE DO NOT SIGN THIS CONSENT FORM.

By clicking “I Agree,” I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF TELEMEDICINE AND RPM, AND BY ACCEPTING THESE TERMS OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN A TELEMEDICINE VISIT AND/OR RPM UNDER THESE TERMS.

What is Telemedicine?

Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. Texas TeleHealth allows you to receive treatment from a healthcare practitioner without having to travel to another location or schedule a separate appointment and helps you avoid long wait times that you might otherwise experience at an in-person visit.

Texas TeleHealth conducts your treatment through audio-video and telephone visits.

What are the Possible Risks to Using Telemedicine?

As with any medical treatment, there are potential risks associated with the use of telemedicine. Texas TeleHealth believes that the likelihood of these risks materializing is very low.

These risks may include, without limitation, the following:

Delays in medical evaluation and consultation treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor video and data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur.

Security protocols could fail, causing a breach of privacy of personal medical information.

Because Texas TeleHealth does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur.

THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR A TELEMEDICINE ENCOUNTER VIA THE SERVICE.

Your Rights and Acknowledgements:

  • You understand that your healthcare information may be shared with other individuals in accordance with the Texas TeleHealth Privacy Policy and regulations or laws in the state or territory in which you are located.
  • You have the same privacy rights via telemedicine that you would have during an in-person visit. Dissemination of any identifiable images or information from the telemedicine visit to researchers or other entities will not occur without your written consent. For more complete information about how we protect your privacy, please read the Texas TeleHealth Privacy Policy.
  • Telemedicine may involve electronic communication of your personal medical information to remote healthcare practitioners who may be located outside of your state.
  • You understand that no results can be guaranteed or assured—you may not achieve the anticipated benefits of the telemedicine services.
  • You understand that all information submitted to Texas TeleHealth will be part of your medical record and available to you by written request to [email protected] in accordance with State and Federal law.

What is RPM?

RPM is the collection of health data outside of a clinical setting (for example, while you are at home or at work) and transmission of that data to your healthcare provider for evaluation. The type of health data collected may include blood pressure, blood glucose, oxygen saturation, heart rate, body weight, and other physiologic data that can help your physician or other healthcare provider monitor your health and make treatment recommendations.

RPM services allow your healthcare provider to monitor your health on an ongoing basis in between visits. This may help your healthcare provider identify issues that need to be addressed sooner than they would without RPM and allows you to communicate your information to your provider without having to travel to your provider’s office. RPM relies on devices and a good Bluetooth and/or internet connection to transmit data, and deficiencies in connection may result in missed readings or failure to transmit information.

Your Rights and Acknowledgements:

  • Your physician or other healthcare provider has explained to you what RPM means, the type of health data that will be collected, and how it will be used in your care;
  • You are aware that your health data will be collected and transmitted digitally from an RPM technology to your healthcare provider in a safe and secure manner to maintain the confidentiality of your healthcare information;
  • You will not transmit or allow to be transmitted the health data of any individual other than your own;
  • You will not intentionally tamper with any RPM device used in connection with your RPM services;
  • Your physician or healthcare provider is not responsible for inaccuracies in the health data transmitted;
  • You consent to the use of RPM services as part of your care and treatment;
  • You are responsible for all applicable copay and deductible amounts (including, if you are a Medicare beneficiary, the 20% copay for Part B services);

This Telemedicine and RPM Informed Consent is valid during your entire treatment with Texas TeleHealth. If you would like to withdraw consent, you must do so prior to receiving any further treatment by writing to us by email at [email protected], or by mail at: 3232 McKinney Ave Ste 500, Dallas, TX 75204.

You understand you may delete your patient account at any time by emailing [email protected]

Telemedicine and RPM services are NOT emergency services, and Texas TeleHealth will not be providing continuous, synchronous, or emergency alerting 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

 Texas Medical Board
Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number:
1-800-201-9353

For more information please visit our website at
www.tmb.state.tx.us