I hereby request, consent and authorize FaceMyDoc and its subsidiaries, affiliates, representatives, and agents (collectively, “FaceMyDoc”) and their employed or contracted physicians, physician assistants, nurse practitioners or other licensed health care professionals in its care network (the “Practitioners”), to utilize telemedicine through FaceMyDoc’s proprietary systems, methods and protocols to access, diagnose, consult, treat and educate me and those I am authorized to represent (the “Services”).
I acknowledge and consent to see a Practitioner via telemedicine. I understand that my eligibility to receive a visit via telemedicine is based on the Practitioner’s medical judgment that it is appropriate and that the quality of care will not be diminished by the use of telemedicine. I understand that a telemedicine visit is distinct from an in-person visit because I will not be in the same room as the health care Practitioner, and instead, I will communicate with the Practitioner through advanced communication technology using live video and audio feed.
I acknowledge that in order to protect my privacy, I need to choose a private location to place my telemedicine call. I understand that in order to provide the best call environment, I should reduce background light from windows or light emanating from behind me. I understand that my camera should be placed on a secure, stable platform to avoid wobbling and shaking during the telemedicine session. To the extent possible, my camera should be placed at the same elevation as my eyes with my face clearly visible to the other person. I understand that I will be informed of the presence of any third party, including those that may be present to assist with the audio or video equipment, and that I have the right to: (1) omit specific details of medical history or physical examination that are sensitive to me during such third party presence, (2) ask non-medical personnel to leave the telemedicine examination room, and/or (3) terminate the consultation at any time by notifying the Practitioner or disconnecting from the telemedicine portal.
I understand the potential risks of receiving the Services via telemedicine include: delays in medical evaluation due to technological equipment failure, a lack of access to all relevant information, or a security breach allowing unauthorized access to my confidential medical information. I understand that my Practitioner or I may terminate the telemedicine visit at any time, including if the Practitioner or I feel that an in-person visit is necessary for any reason. I have had the Services and alternatives to telemedicine for my Services explained to me and I choose to and continue with a telemedicine visit.
I understand that any complaint may be filed with the Secretary of the Department of Health and Human Services.
I have read and understood the written information provided above. I agree that the information provided above adequately explains the Services, along with the risks and benefits to me of said Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full.
If you have any questions, please contact firstname.lastname@example.org.