CONSENT TO TELEHEALTH VISIT (TELEVISIT) 1. Purpose: The purpose of this form is to obtain your consent for a televisit with dermatologists (MD and PA) at Dermatology Center of Loudoun. The purpose of this visit is to help in the care of your skin problem without sharing the same physical space. 2. How Televisits Work: In a televisit, you will interact in real time with your dermatologist via a secure online videoconferencing technology. Additionally, it is recommended that you submit photos of your chief complaint via secured electronic messaging should the videoconference connection or resultant audio/video be of poor quality, to supplement the information in the televisit. The dermatologist will look at your skin during a videoconference and/or review the photos you submitted. The dermatologist will then give you advice about your skin condition and how to treat and take care of your condition. The information from the dermatologist may not be the same as a face-to-face visit because the dermatologist is not in the same room. You may be required to make an in-person appointment for further evaluation and follow-up in the future. 3. Pros, Cons and Your Options: With televisits, a dermatologist will advise you based on viewing your condition during a videoconference and based on any photos that were submitted electronically. Sometimes a face-to-face follow-up visit with the dermatologist may still be needed. If you do not come into the office for an in-person visit, the dermatologist’s advice will be solely based on viewing your skin condition during a videoconference or on the information and images provided by you electronically. In the absence of an in-person physical evaluation, the dermatologist may not be able to collect all the details of your skin condition which may limit or affect her assessment, diagnosis or treatment of your condition. It is possible that there will be errors or deficiencies in the transmission of the images of your skin condition during the videoconference, or in the photos submitted electronically, that may impede the dermatologist’s ability to advise you about your condition. Also, very rarely, security measures can fail to protect your personal information, but the company that is providing the technology for your televisit has extensive security measures in place to prevent such failures from happening. 4. Presence of Others During Televisit: People other than your doctor may be a part of your care and present (physically or via phone/video) during a televisit. These people may be a medical assistant and an administrative assistant. There may also be non-medical people who may help set up or troubleshoot the videoconferencing equipment before or during the televisit. You may ask for persons other than your dermatologist to leave the room (or end their connection) if you are uncomfortable having them participate in your televisit. 5. Medical Information and Records: All federal and state laws covering access to your medical records (and copies of medical records) also apply to your televisit. No one other than the health care team described above can view your photos or information unless you agree to give them access. 6. Privacy: All information given at your televisit will be maintained by the doctors, other health care providers, and health care facilities involved in your care and will be protected by federal and state privacy laws. 7. Your Rights: You may opt out of the televisit at any time. This will not change your right to future care or health benefits. 8. Waiver/Release: By signing below, you understand and agree that you solely assume the risk of any errors or deficiencies in the electronic transmission of information during your televisit or in the electronic submission of your images to your dermatologist. You further understand that no warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis. To the extent permitted by law, you also agree to waive and release your dermatologist and her practice from any claims you may have about this advice or the televisit generally. My doctor has given me all pertinent information about televisits. I have had the chance to ask questions and all of my questions have been answered. I have read this form, understand the risks and benefits of the televisit, and agree to a televisit under the terms explained above.