"I understand and agree that I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services. If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with 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.
1. By using the Celebration Family Physicians telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my Celebration Family Physicians provider and I will be able to see and speak with each other from remote locations.
2. I understand and agree that:
▪ I will not be in the same location or room as my medical provider.
▪ My Celebration Family Physicians provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.
▪ Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my Celebration Family Physicians provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
▪ Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment;
(ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Celebration Family Physicians responsible for lost information due to technological failures.
▪ I further understand that my Celebration Family Physicians Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my Celebration Family Physicians provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
▪ I may discuss these risks and benefits with my Celebration Family Physicians provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by Celebration Family Physicians.
▪ I understand that the level of care provided by my Celebration Family Physicians provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to visit the office of Celebration Family Physicians, hospital emergency department or other appropriate health care provider.
▪ I have the right to receive face-to-face medical services at any time by traveling to a Celebration Family Physicians medical center that is convenient to me.
▪ In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
3. I consent to, understand and agree that:
▪ I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
▪ Celebration Family Physicians will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
▪ Before prescribing any controlled substance to me, Celebration Family Physicians may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.
▪ My Celebration Family Physicians provider will not prescribe opioids to me during a telehealth visit.
▪ I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Celebration Family Physicians’ standard policies regarding request and receipt of medical records and applicable law.
▪ The laws of the state in which I am located will apply to my receipt of telehealth services."