Telehealth Informed Consent Form

I, [Patient Name], hereby confirm that I have been fully informed about the use of telehealth services provided by United Medical Group (UMG) through the WWW.YOURMD.ONLINE telehealth electronic health record (EHR) platform. I understand that telehealth involves the use of electronic communications such as video or telephone communication to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists.

I understand that 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
• I understand that 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. I understand that encryption will be used to protect private data.

1. I understand the potential benefits of telehealth, such as improved access to medical care, more efficient medical evaluation and management, and access to medical providers during off-business hours and holidays. I also understand the potential risks associated with telehealth, such as the poor resolution of images, delays in medical evaluation and treatment, and the possibility of security breaches.
2. I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telehealth and that no information obtained in the use of telehealth that identifies me will be disclosed to researchers or other entities without my explicit consent.
3. 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. Inspect all information obtained and recorded in the course of a telehealth interaction, and receive copies of this information for a reasonable fee. Choose alternative methods of medical care at any time. Be informed of any electronic communication of my personal medical information to other medical practitioners and outside provider referrals as required for the purpose of my medical care.
4. I understand that WWW.YOURMD.ONLINE is a telehealth electronic health record (EHR) used by United Medical Group for the purpose of offering telehealth services through their contracted medical providers. I understand that it is my duty to inform my primary care physician and other medical providers of electronic interactions regarding the care that I may have with United Medical Group via the WWW.YOURMD.ONLINE telehealth EHR.
5. I understand that telehealth consultations are provided for general information and educational purposes only and are not intended to diagnose, treat, cure, or prevent any disease or condition. I understand that the information provided during a telehealth consultation is not intended to create a patient-provider relationship and that patients are advised to consult with a licensed healthcare professional for any specific medical issues or concerns.
6. I understand that telehealth is not appropriate for emergency or urgent care and that in such cases, I should seek immediate medical attention from an emergency department or call 911.
7. I understand that the quality of the telehealth visit may be affected by factors such as internet connectivity and technical difficulties and that my healthcare provider may need to reschedule or conduct the visit in person if these issues arise.
8. I understand that by signing this informed consent, I am giving my explicit and informed consent for United Medical Group providers to communicate with me via telehealth and share my medical information as necessary for my care and that my information will be protected in accordance with HIPAA regulations.
9. I have read and understand the above information and give my explicit consent to participate in telehealth services provided by United Medical Group (UMG) through the WWW.YOURMD.ONLINE telehealth electronic health record (EHR) platform.

Signature of Patient (or a person authorized to sign for the patient): 

Date: 

If authorized signer, relationship to patient: Witness: Date: I have been offered a copy of this consent form.