INFORMED CONSENT FOR TELEHEALTH SERVICES
YOU UNDERSTAND THAT BY CHECKING THE “AGREE” BOX YOU ARE AGREEING TO THIS INFORMED CONSENT AND THAT IT CONSTITUTES A LEGAL SIGNATURE ON THIS INFORMED CONSENT FOR TELEHEALTH SERVICES.
Portrait is pleased to offer telehealth services as a convenient option to consult with you and address your healthcare needs. Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment and follow-up. The telehealth services we offer may also include chart review, remote prescribing, health information sharing, and patient education.
During your telehealth consultation, details of your medical history and personal health information may be discussed through the use of interactive video, audio and telecommunications technology. A physical examination of you may also take place, and video, audio and/or photo recordings may be taken. The telehealth services we provide may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output date from medical devices and sound and video files.
The electronic communications systems we use 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 ensure its integrity against intentional and unintentional corruption.
Our physicians, physician assistants and nurse practitioners are in addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
The purpose of this form is to obtain your consent for a telemedicine consultation with a Portrait healthcare provider.
Anticipated Benefits Of Telehealth Services
The use of telehealth services may have the following benefits:
- Making it easier and more efficient for you to access medical care and treatment;
- Allowing you to obtain medical care and treatment from our healthcare providers at times that are convenient for you;
- Enabling you to interact with our healthcare providers without the necessity of an in-office appointment; and/or
- Improved access to care by enabling you to remain in your home while our healthcare providers consult and obtain test results at other sites.
While the use of telehealth services can provide potential benefits for you, there are also potential risks associated with the use of telehealth. These risks include, but may not be limited to, the following:
- In rare cases, your healthcare provider(s) may determine that the transmitted information is of inadequate quality to allow for appropriate medical decision making, and it may be necessary for you to reschedule a telehealth consult or to schedule an appointment with your primary care physician.
- The inability of your healthcare provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent them from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
- Your healthcare provider(s) may not be able to provide medical treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services.
- Delays in medical evaluation/treatment could occur due to the unavailability of your healthcare provider(s) or deficiencies or failures of the technology or electronic equipment.
- In very rare instances, the electronic systems or other security protocols or safeguards used in providing telehealth services could fail, causing a breach of privacy of your medical or other information.
- A lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
- As telehealth services take place outside of the medical office, there is a potential for other people to overhear the consultation. We will take reasonable steps to ensure your privacy. It is important for you to make sure you find a private place for the consultation where you will not be interrupted. It is also important for you to protect the privacy of the consultation on your cell phone or other device, and that you be in an area where other people are not present and cannot overhear your conversation with your healthcare provider.
Patient Acceptance and Consent
By clicking the button titled “I Agree and Consent” on the electronic version of this form, you acknowledge that you have thoroughly read and understand this Informed Consent for Telehealth Services, and that you agree with each of the following:
- I understand that I should never use telehealth services in a medical emergency. I understand that, in an emergency, I should dial 911 or go to an emergency department.
- I hereby consent to receiving services via telehealth technologies. I understand that Portrait and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Portrait provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
- I understand that Portrait only provides services to patients in California and confirm I am currently located within California and this is where I will be receiving consultations and services.
- I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Portrait will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
- I understand there is a risk of technical failures during the telehealth encounter beyond the control of Portrait. I agree to hold harmless Portrait for delays in evaluation or for information lost due to such technical failures.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that, if I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and that the Portrait providers are not able to connect me directly to any local emergency services.
- I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Portrait provider (e.g. labs or bloodwork).
- I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Portrait provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
- I understand the importance of answering all questions fully and truthfully. I understand that the Portrait has no way of verifying the information and photos that I provide and that the Portrait healthcare provider will consider all the information I provide to be accurate, true and complete, including my age, gender and all my answers to health questions, and the photos to be of me, taken at the time of me using the service, and unaltered.
- I understand that if I provide information that isn't true and complete, then I will be at greater risk of adverse events from any treatment that my healthcare provider prescribes and I may be prescribed a treatment that isn't necessary, appropriate, or safe.
- I understand that if I provide photos that are altered, not of me or not taken at the time of me using the service, then I'll be at greater risk of adverse events from any treatment that the healthcare provider prescribes and I may be prescribed a treatment that isn't necessary, appropriate, or safe.
- I understand that, even if I provide information that is true and complete, I'm still at risk of adverse events from any treatment that my healthcare provider may prescribe.
- I understand that it is my responsibility to make an informed decision whether to accept a treatment plan that my healthcare provider proposes after weighing the risks and benefits of any medication or treatment being prescribed, alternative treatment options, and the risks and benefits of such alternatives, and the option of not seeking any treatment.
- I understand that, if I participate in a telehealth consultation, I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
- I have had the opportunity to discuss the telemedicine services with Portrait and have had all of my questions answered to my satisfaction.
- I hereby give my informed consent for the use of telemedicine in my medical care. I hereby authorize Portrait and its healthcare providers to use telemedicine in the course of my diagnosis and treatment.
Partner Pharmacy Contact Information
Prescriptions are filled by our partner pharmacy:
Welcare Pharmacy Compounding & Prescriptions
1921 W San Marcos Blvd #140
San Marcos, CA 92078
+1 (760) 727-3333