Telemedicine Informed Consent

  • Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

    1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.

    2. I understand that I will not be physically in the same room as my healthcare providers. I will be notified of and my consent obtained for anyone other than my healthcare provider(s) present in the room.

    3. I understand there are potential risks to using technology, including service interruptions, interception, and technical difficulties.

      a. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

    4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in the medical record. I also understand that my refusal will not affect my right to future care or treatment.

      a. I may revoke my right at any time by contacting Texas Ear, Nose & Throat Specialists, Director of Patient Experience at 281-897-0416

    5. I understand that the laws that protect patient privacy and the confidentiality of health care information apply to telemedicine services.

    6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

      a. I understand that my insurance carrier will have access to my medical records for quality review/audit.
      b. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurance that apply to telemedicine visits.
      c. I understand that my health plan payment policies for telemedicine visits may be different from policies for in-person visits.

    7. I understand that this document will become part of my medical record.

    Notice Concerning Complaints: Complaints about physicians, as well as other licensees and registrants for the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board – Attention: Investigations – 333 Guadalupe, Tower 3, Suite 610 – P.O. Box 2018, MC-263 – Austin TX 787-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information, please visit

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