I agree to participate in a telemedicine evaluation. By signing this agreement, I authorize the electronic transmission of my medical information and/or video conference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small]. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a healthcare professional in person. I understand that medical records of telemedicine services will be kept at Congruence in Care but upon request can be sent to your primary care provider’s office.
HIPAA PRIVACY NOTICE:
The department of Health and Human Services, Office of Civil Rights, Under the Public Law 104-191, (The Health Insurance Portability and Accountability Act of 1996) (HIPAA), mandates that we issue this revised Privacy Notice to our patients. You are urged to read this. Our privacy notice informs you of our use and disclosure of your Protected Health Information (PHI), defined as: "any information, whether oral or recorded in any medium, that is either created or received by a health care provider, health plan, public health authority, employer, life insurance company, school or university or clearing house that relates to the past, present or future physical or mental health or condition of any individual, the provision of health care to an individual." Out office will use or disclose your PHI for purposes of treatment, payment, and other healthcare purposes as required to provide you the best quality healthcare services that we offer. It is our policy to control access to your PHI; and even in cases where access is permitted, we exercise a "minimum necessary information" restriction to that access. You, as our patient, may revoke any consent at any time and all use, disclosure and administration of related healthcare services will be revised accordingly. With the exception of matters already in process. To revoke the consent, you will have to provide this office with a written request with your signature and date. Any revocation will not apply to information already used or disclosed. You, the patient have access to your health care information and may request copies of your information, and under the law you may request amendments to your information. The physician will exercise professional judgment with regards to requests for amendments and is not bound by law to make any changes. If the physician agrees with the request, we are bound by law to abide to any changes.