Telemedicine Consent Form
Purpose
The purpose of this form is to obtain your informed consent for a telemedicine consultation with Dr. Alexandra Laya, to assist in the diagnosis or treatment of a gastrointestinal or liver condition.
Introduction
Telemedicine involves the use of electronic communication such as phones or other electronic devices to enable a patient to consult with their physician about their medical problems and other health concerns and is facilitated by sharing and obtaining information through any of the following:
Live two-way audio and video
Medical images
Patient medical records
Services Provided
Services include patient consultation, diagnosis and recommendations, which may also include chart review, remote prescribing and patient education.
Electronic communication systems of SeriousMD (https://seriousmd.com) and the Now Serving application will incorporate network and software security protocols to protect the confidentiality of patient information, and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional information breaches.
Expected Benefits
Improved access to medical care by enabling a patient to remain at home while the physician offers diagnosis and treatment from a distant site.
More accessible, efficient and timely medical evaluation and management.
Obtain expertise recommendations from a Gastroenterologist specialist.
Possible Risks
As with any medical procedure, there are also potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
Information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician.
Consultation is completed online and no direct physical examination is possible. Without this, medical decisions may be inappropriate and can potentially lead to delays in diagnosis or treatment.
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgment error.
Despite efforts to protect patient confidentiality, online security protocols could fail, causing a breach of privacy of personal medical information.
Service Limitations
Telemedicine consults offered by Dr. Alexandra Laya are for non-urgent medical concerns, and is only available by appointment. If the patient believes they are experiencing a medical emergency, they should proceed to the emergency room.
The responsibility for the patient’s overall medical care remains with their primary care physician. If the patient does not have one, they are strongly encouraged to find one to establish continuity of care.
Financial Responsibility
Telemedicine provided by Dr. Alexandra Laya is a medical consultation service that is directly billed to the patient at the end of the encounter. If the patient has medical insurance, the doctor can complete forms to assist in filing for reimbursement. However, Dr. Alexandra Laya will not be responsible should insurance deny coverage for the claim.
BY SIGNING THIS FORM, I HEREBY DECLARE THAT:
I have read this form completely and that I fully understand what is stated here;
I was given an opportunity to ask questions and my questions were answered to my satisfaction by the doctor or her designated assistants;
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
I understand that I have been informed in advance that I am financially responsible for the consultation fee and that these services may not be reimbursable by my health insurance plan.
No form of video or audio recording is permitted by either the patient or the physician during the telemedicine consultation unless otherwise agreed upon.
I attest that I am located in the Philippines and will be present in the Philippines during all telehealth encounters.