Registration – Telemedicine Consent

    • Texas Regional Clinic

      8301 Katy Freeway | Ste 101 | Houston, Texas

      Scheduling Direct Line: (713)489-1741

      Fax: (713)984-8481




    • I.   Introduction.

      Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.

    • II.   Consent for Treatment.

      I voluntarily request Texas Regional Clinic physician(s) and such associates, residents, technical assistants and other health care providers as they may deem necessary (“Texas Regional Clinic Telemedicine Providers”) to participate in my medical care through the use of telemedicine. I understand that Texas Regional Clinic Telemedicine Providers (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that Texas Regional Clinic Telemedicine Providers’ advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure. If Texas Regional Clinic Telemedicine Providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies dial 911, or go to the nearest hospital emergency department.

    • III.   Release of Information.

      To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my medical record (including oral information) to Texas Regional Clinic Telemedicine Providers. I understand and agree that the information I am authorizing to be released may include: 1) AIDS/HIV test results, diagnosis, treatment, and related information: 2) drug screen results and information about drug and alcohol use and treatment; 3) mental health information; and 4) genetic information. I understand that the disclosure of my medical information to Texas Regional Clinic Telemedicine Providers, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering. I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.

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      (Today's Date)
    • Your Signature (Type Your Name)

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