Disclosure and Consent Telemedicine and Telehealth

I. Introduction:  Telemedicine and telehealth services (hereafter, “telemedicine”) involve remote interactions through telecommunication technologies between a health care provider and a patient at a different location, in order to provide real-time evaluation, diagnosis, consultation, and treatment of a health condition. The technologies may involve the use of telephone, video, or other two-way communication mediums, electronic patient portals, remote transmission and review of health information, or other methods.

II.  Consent for Telemedicine Treatment:  I voluntarily request and give permission (consent) for MD Anderson physician(s), and any associates, technical assistants, and/or other health care providers as they may deem necessary (“MD Anderson Telemedicine Providers”), to provide me medical and/or health care through telemedicine technology and services.

I understand that MD Anderson Telemedicine Providers may:

• Conduct their practice and medical care in a different location than the one where I may be physically present
• Not have the opportunity to perform an in-person physical exam of me at the time my telemedicine services are provided
• Rely on information given by me before and during our telemedicine services appointment

I understand that I must provide information to the best of my knowledge and ability that is complete and accurate. This includes information about my medical history, condition(s), and current or previous medical care.

I understand that the MD Anderson Telemedicine 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 the distortions of diagnostic images or specimen due to electronic transmission issues.

I understand that if telemedicine services are interrupted due to a technology problem or equipment failure or other reason, a different way of communication may need to be used and/or I may need to have an in-person medical evaluation with a health care provider located in my area.

I understand that the level of care provided by MD Anderson Telemedicine Providers is to be the same level of care that is available to me through an in-person medical visit. If MD Anderson Telemedicine Providers determine that the telemedicine services will not adequately address my medical needs, the treating MD Anderson Telemedicine Provider(s) may require me to schedule and attend an in-person appointment with my health care provider.

I understand that if I experience any urgent medical symptom(s) or condition(s) after a telemedicine session, I should dial 911 or go directly to the nearest emergency room.

I understand that I am responsible for any copayment or deductible amounts associated with telemedicine visits, in accordance with my insurance company’s policies. If my insurance company does not cover telemedicine visits, I understand I am financially responsible for the cost of such visits.

I have been given an opportunity to ask questions about the telemedicine services to be provided to me. I understand the risks and hazards involved with telemedicine services. I believe that I have enough information to give informed consent to receive telemedicine services by MD Anderson Telemedicine Providers.

Notice concerning complaints

I acknowledge that complaints about physicians, as well as other licensees and registrants of 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, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353

For more information, please visit the following website: www.tmb.state.tx.us