Introduction

Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which includes the use of interactive audio and video allowing members of Dr Rao’s ENT staff and providers to see and communicate with the patient in real-time.

Consent for Treatment. I voluntarily request Dr Rao’s ENT to participate in my medical care through the use of telemedicine. I understand that Dr Rao’s ENT providers (i) will not be physically present for your medical care, (ii) will not have the opportunity to perform an in-person physical examination, and (iii) will solely rely on information provided by me. I acknowledge that Dr Rao’s ENT providers’ advice, recommendations, and/or decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.

If Dr Rao’s ENT providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies dial 108, or go to the nearest hospital emergency department.

Due to limitations of telemedicine evaluation, management, and treatment, I understand that I may be asked to perform certain tests/examinations that may result in more than one telemedicine session.

Release of Information

To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my medical record (including oral information) to Dr Rao’s ENT. I understand and agree that the information I am authorizing to be released may include sensitive medical history and/or information. I understand that the disclosure of my medical information to Dr Rao’s ENT, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering. I certify that I have read it or have had it read to me, and that I understand its contents.