MediSan Health is constantly striving to provide better care for our patients. To better serve your needs, some health care services will be made available through Telemedicine. This will allow for a two way interactive video and audio communication for the evaluation and treatment of a variety of medical problems. These problems must be deemed appropriate for a Telemedicine visit by the consulting Physician. I understand and agree to the following:

1. Physicians part of MediSan Health may be at different locations besides the office when conducting medical care. This location will uphold the privacy as that of a regular office visit. I understand that this consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

2. The Services will not be used for medical emergencies or other time-sensitive matters. If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.

3. Electronic communication is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed. You are responsible for following up on the Physician’s electronic communication and for scheduling appointments where warranted.

4. You agree to inform the Physician of any types of information you do not want sent via the telemedicine services

5. Once seen in consultation, a record of the visit will be permanently made in your medical file via the EMR used in MediSan Health and hence can be seen by other Physicians involved in your medical care.

6. Video transmission will consist of the Patient and the consulting Physician. This video will not be recorded.

7. Telemedicine visits are to be used for medical issues that do not require a physical examination. Lab work review, referrals to specialists and certain medication refills are part of services that are offered via Telemedicine. It is important to note that the consulting Physician will deem what can and cannot be conducted for the visit.

8. Although this service is intended to be conducted through a two way interaction, I understand that there are potential risks to this technology, including interruptions, unauthorized access and other technical difficulties. I understand that the consulting physician or myself can discontinue the consult if videoconferencing connections are not adequate.

9. I understand that the consulting Physician will be able to access Pharmanet, if needed, to review medications that I am taking. This is needed when a prescription refill is the reason for the visit or when otherwise deemed appropriate by the physician.

10. The consulting Physician will NOT be prescribing Stimulants, Narcotics or Benzodiazepines over Telemedicine.

11. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

12. I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of telemedicine services. I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.