Telehealth Consent

I consent to engage in Telehealth services with the providers (physician, nurse practitioner, or physician assistant) at Advanced Urology Institute (AUI). For the purposes of this consent, the term Telehealth refers to both combined video and audio services as well as audio-only (phone services).

I understand that Telehealth is a means of delivering health care services rather than in-person services. Rather than an office visit, I will be receiving services by telephone or video via electronic communication technologies over the internet or phone. The purpose of the services is the same as an in-person visit and will be used as a means to communicate with my provider to help in diagnosis, consultation, treatment, education, and care management for my health concerns.

By signing this form, I agree to the following:

  1. I have a right to confidentiality regarding my treatment and related communications under the same laws that protect the confidentiality of my in-person visits (HIPAA and Informed Consent).
  2. I understand the risks associated with participating in Telehealth, including but not limited to the possibility of disrupted or distorted communications due to technical failures and possible access by unauthorized persons, despite reasonable efforts and safeguards on the part of AUI employees and providers.
  3. I understand that I have the option of an in-person visit rather than Telehealth and can decline the services at any time. This will change my ability to receive future care from AUI.
  4. In some instances, Telehealth may not be as effective or be a reasonable option for my healthcare needs, and an in-person visit may be recommended by my provider.
  5. I understand that I am responsible for conducting the visit in a private area free from distractions or intrusions and that there is a risk of being overheard by persons near me. It is also important to use a secure network and take reasonable steps to protect myself.
  6. Some Telehealth platforms allow for video or audio recordings. Neither I (the patient) nor the provider may record the sessions without the other party’s written consent.
  7. My Telehealth visit will be charged to my insurer or to me personally (if I do not have insurance or it is not a covered service). AUI will make reasonable efforts to obtain authorization if necessary and verify coverage of the service, but we cannot guarantee that my insurance will cover this without cost to me, as payer rules change frequently.