Consent to Use Telemedicine

    I am physically located in California. At the beginning of each telemedicine session, I will help my
    doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my
    full name, my current location, my readiness to proceed, and whether I am in a situation conducive to
    private, uninterrupted communication. By signing this consent, I understand and agree:
    I. My doctor is located in and licensed by the State of California. My doctor may not be able to
    prescribe medications for me and/or may not be able to assist me in an emergency situation
    when I am located in any other state or country. If I require medication, I may contact my
    doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency
    room for help.
    2. I submit to the exclusive jurisdiction of the California state superior courts and agree that any
    claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services
    provided by my doctor and my doctor's staff will be brought solely and exclusively in
    California state superior courts. I also agree that the interpretation of this consent will be
    exclusively governed by and construed in accordance with the laws of California.
    3. My doctor believes that telemedicine services are appropriate for my medical condition and
    that I would benefit from its use despite its risks and limitations. While I may expect
    anticipated benefits from the use of telemedicine, no specific results can be guaranteed or
    assured.
    4. I received an explanation of how the electronic communications technology will be used for the
    telemedicine services. I am comfortable with using electronic communications technology to
    communicate with my doctor and understand there are limitations to the technology which may
    require an in-person consultation.
    5. I agree to have the necessary computer, equipment and internet access for my telemedicine
    communications. I also agree to arrange for a location with sufficient lighting and privacy and
    is free from distractions and intrusions during my telemedicine communications.
    6. The laws that protect privacy and the confidentiality of my medical information also apply to
    telemedicine. The medical infonnation that is transmitted electronically by my doctor to me
    will be encrypted during transmission and will be stored only by my doctor or a service
    provider selected by my doctor. I w1derstand the dissemination of any personally-identifiable
    images or infonnation from the telemedicine communication to researchers or other healthcare
    providers will not occur except as required by federal or California state law.
    7. I understand my risks of a privacy violation increase substantially when I enter infonnation on
    a public access computer, use a computer that is on a shared network, allow a computer to
    "autoremember" usemames and passwords, or use my work computer for personal
    communications. I also understand it is my responsibility to encrypt medical infonnation I
    transmit electronically to my doctor and my failure to use technical safeguards, such as
    encryption, increases my risks of a privacy violation.
    I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any
    questions I had with my doctor and all of my questions were answered to my satisfaction.

    Name:








    Consent to Use of Telemedicine

    I am physically located in California. At the beginning of each telemedicine session, I will help my
    doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my
    full name, my current location, my readiness to proceed, and whether I am in a situation conducive to
    private, uninterrupted communication. By signing this consent, I understand and agree:

    1. My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help.
    2. I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor’s staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
    3. My doctor believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
    4. I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.
    5. I agree to have the necessary computer, equipment and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications.
    6. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
    7. I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “autoremember” usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.

    I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction.

    Name:
    Date:
    Signature: