Telehealth Informed Consent & Patient Notice
Innovation Hydration Wellness Center
What Is Telehealth?
Telehealth allows a patient and healthcare provider to communicate when they are not physically in the same location.
Innovation Hydration Wellness Center may use secure video, audio, electronic communications, patient portals, or other appropriate technologies to conduct certain healthcare encounters.
Telehealth may be used for evaluation, consultation, follow-up care, review of symptoms, discussion of diagnostic testing, treatment planning, medication management, patient education, and other clinically appropriate healthcare services.
How Innovation Hydration Telehealth Works
Depending upon your healthcare needs, Innovation Hydration may provide:
Virtual Sick Visits
An eligible patient may complete the entire encounter remotely when the treating healthcare provider determines that the patient's condition can appropriately be evaluated through telehealth.
Express Care Visits
Some symptoms require additional information that cannot reasonably be obtained through a virtual visit alone.
You may be asked to visit Innovation Hydration for appropriate clinical intake, vital signs, specimen collection, and/or diagnostic testing before completing a telehealth evaluation with a healthcare provider.
Benefits of Telehealth
Potential benefits include:
Convenient access to healthcare;
Reduced travel;
Reduced time spent in waiting rooms;
Access to a healthcare provider from home or another appropriate location;
Efficient follow-up and continuity of care; and
Improved access when an in-person provider visit may not otherwise be convenient.
Limitations and Risks of Telehealth
I understand that telehealth also has limitations and potential risks.
These may include:
A provider's inability to perform a complete physical examination;
Limitations in evaluating certain symptoms remotely;
Technical failures or interruptions;
Delays or inaccuracies caused by incomplete patient information;
Privacy and security risks associated with electronic communications;
A need for laboratory or diagnostic testing;
A need for subsequent in-person examination;
A need for referral to another healthcare professional or facility; and
A medical condition being more serious than initially apparent through a virtual evaluation.
The healthcare provider may stop a telehealth encounter or recommend another level of care when telehealth is not clinically appropriate.
Privacy and Security
Innovation Hydration takes reasonable steps to protect the privacy and security of patient information during telehealth encounters.
Healthcare information associated with telehealth is handled according to applicable privacy and security requirements and Innovation Hydration's Notice of Privacy Practices.
Patients should participate from a private location whenever possible and use a secure internet connection.
Patients should inform the provider if another person is present during the telehealth appointment.
HHS similarly recommends private settings, secure connections, identity verification and reasonable safeguards during virtual encounters. telehealth.hhs.gov
Patient Identity and Location
At the beginning of a telehealth encounter, Innovation Hydration may ask the patient to confirm information including:
Full name;
Date of birth;
Current physical location;
Telephone number;
Identity when necessary; and
Whether anyone else is present during the encounter.
Your physical location is important because healthcare professionals generally must be authorized to provide healthcare in the jurisdiction where the patient is located.
Technology
Telehealth requires functioning electronic technology and internet or telephone connectivity.
Technical problems may occasionally prevent or interrupt an encounter.
If the telehealth connection fails, Innovation Hydration may attempt to reconnect, contact you using the telephone number on file, reschedule the appointment, or recommend another method of evaluation.
Recording
Innovation Hydration does not routinely record telehealth encounters.
A telehealth encounter will not be intentionally recorded by Innovation Hydration without appropriate notice and consent where required.
Patients should likewise not record a telehealth encounter without first informing the healthcare provider and obtaining any consent required by applicable law.
Prescriptions
I understand that participating in a telehealth appointment does not guarantee that I will receive a prescription.
Medication will be prescribed only when the treating healthcare provider determines that prescribing is clinically appropriate and permitted by applicable law and professional standards.
The provider may require diagnostic testing or an in-person evaluation before prescribing medication.
When Telehealth Is Not Enough
The provider may recommend that I receive:
An Express Care Visit;
Laboratory testing;
Diagnostic testing;
An in-person physical examination;
Urgent care evaluation;
Emergency department evaluation;
Specialist care; or
Other appropriate healthcare services.
I understand that following these recommendations is my responsibility.
Emergencies
Telehealth appointments with Innovation Hydration are not emergency medical services.
If I experience symptoms that I believe constitute a medical emergency, I understand that I should call 911 or seek immediate emergency medical attention.
I should not wait for a scheduled Innovation Hydration appointment in an emergency.
Patient Responsibilities
By participating in telehealth, I agree to:
Provide accurate and complete medical information;
Provide an accurate medication and allergy history;
Answer clinical questions truthfully;
Inform the provider of significant changes in my condition;
Tell the provider where I am physically located;
Participate from a reasonably private location whenever possible;
Ask questions when I do not understand something;
Follow appropriate treatment and follow-up recommendations; and
Seek emergency care when necessary.
Consent
By signing or electronically acknowledging this consent, I confirm that:
I have read and understand the information above.
I understand the nature, potential benefits, limitations, and risks of telehealth.
I understand that telehealth may not be appropriate for every condition.
I understand that I may be asked to receive diagnostic testing or an in-person evaluation.
I understand that a telehealth appointment does not guarantee a prescription or any particular treatment.
I have had an opportunity to ask questions concerning telehealth.
I voluntarily consent to receive healthcare services through telehealth from Innovation Hydration Wellness Center and its healthcare providers.
Patient Name: ______________________
Date of Birth: ______________________
Patient/Legal Representative Signature: ______________________
Date: ______________________
Relationship to Patient, if applicable: ______________________