HIPPA and Telemedicine Consent
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), established a Privacy Rule to help insure that personal health care information is protected for privacy. The Privacy Rule was also created to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.
As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate or necessary, we provide the minimum necessary information only to those we feel are in need of your health care information regarding treatment, payment or health care operations, in order to provide health care that is in your best interest.
We fully support your access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with the physician and not patients) and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent
You may refuse to consent to the use or disclosure of your personal health information, but this must be done in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information. If you choose to give consent in this document, at some future time you may request to refuse all or part of your Personal Health Information. You may not revoke actions that have already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our Privacy Notice (Compliance Assurance Notification to Our Patients), to request restrictions and revoke consent in writing.
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
1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person
2. I understand that I will not be physically in the same room as my health care provider. I will be
notified of and my consent obtained for anyone other than my healthcare provider present in the
3. I understand that 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 health care 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 my 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 any of the UCHA Facilities
5. I understand that the laws that protect 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
b. I understand that I will be responsible for any out-of-pocket costs such as copayments or
coinsurances that apply to my telemedicine visit.
c. I understand that health plan payment policies for telemedicine visits may be different from
policies for in-person visits.
7. I understand that this document will become a part of my medical record.