Telehealth Appointments

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Disclaimer:

1. I understand that I am registering for a telehealth appointment with the San Diego Ear, Nose, and Throat Specialists.

2. I understand that telehealth technology will be used to connect me with a provider. Telehealth appointments may be conducted by videoconferencing. I understand that this appointment 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. I understand that the health care provider will be unable to complete a physical examination during this visit.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. I understand that I can discontinue the telehealth appointment at any time.

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the appointment other than my healthcare provider to complete documentation and orders. The above-mentioned people will all maintain confidentiality of the information obtained.

5. I have had the alternatives to a telehealth appointment explained to me, and in choosing to participate in a telehealth appointment, I understand that some parts of the evaluation such as physical examination or on-site testing will be unavailable.

6. In an emergency situation, I understand that the responsibility of the telehealth specialist or provider may be to direct me to emergency medical services, such as the emergency room.

7. I understand that billing for the telehealth appointment will occur from 1) the primary care provider and 2) telehealth provider, and 3) as a facility fee from the site from which I am presented. Billing is at the discretion of the provider. Billing procedures will be explained to me.

8. I have read this document carefully, and understand the risks and benefits of the telehealth appointment and have had my questions regarding the procedure explained and I hereby consent to participate in a telehealth appointment visit under the terms described herein.

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