Authorization and Consent to Participate in Telemedicine Consultation

The purpose of this form is to obtain your consent both for you and/or, as applicable, for your child or other minor for whom you are acting as a guardian to participate in a telemedicine consultation with one of Montana Pediatrics physicians, nurses, or other healthcare providers and is referred to as the “Clinic.” As used in this document, “you”, “your”, and “Patient” are deemed to include either yourself, if you are being treated, or any child for whom you are a parent or guardian if the child is receiving treatment.

Nature of Telemedicine Consultation

Telemedicine involves the use of audio, video or other electronic communications to interact with you, the Patient, consult with the Patient’s healthcare provider(s) and/or review your and/or the Patient’s medical information for the purpose of diagnosis, therapy, follow-up and/or education. During the telemedicine consultation:

a) Details of your and/or your child’s medical history, examinations, x-rays, and tests may be discussed with other health professionals through the use of interactive video, audio and telecommunications technology.

b) Physical examination of you or your child may take place.

c) Nonmedical technical personnel may be given access to the telemedicine consultation and/or technology to assist in ensuring effective transmission and, in general, proper functioning of technology.

d) Video and/or audio recordings may be made and and/or photos may be taken.

Medical Information and Records

Laws regarding your or the Patient’s access to medical information and copies of medical records also apply to telemedicine. Unless authorized by applicable law, no images or information from the telemedicine consultation that identify you or the Patient will be provided to third parties without your consent.

Confidentiality

Reasonable and appropriate efforts have been made to eliminate confidentiality risks associated with the telemedicine consultation. Information disclosed during the telemedicine consultation is subject to confidentiality protection under applicable law.

Risks, Benefits and Alternative

The benefits of telemedicine include having access to healthcare providers, medical information and education without having to travel to a healthcare facility. A potential risk of telemedicine is that because of the Patient’s specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine consultation. Another risk is that you or the Patient may find it difficult or uncomfortable to communicate using the telemedicine platform. Additionally, in rare circumstances, the telemedicine technology could be faulty or security protocols could fail, resulting in a breach of confidentiality or privacy. The alternative to telemedicine consultation is a face-to-face visit with a healthcare provider.

Rights

You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your or the Patient’s right to future care or treatment or risking the loss or withdrawal of any benefits to which you or the Patient would otherwise be entitled. You have the option to consult with the healthcare provider conducting the telemedicine visit in person if you travel to his or her location.