Phone

903.784.1608

Email

info@hayesclinic.com

Opening Hours

Mon - Thurs: 10AM - 5PM , Fri: 9AM - 1PM

TeleMed Informed Consent Disclosure

By electronically signing this form, I understand and agree with the following:
TeleMed involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.
Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, my family members, caregivers, or other legal representatives or guardians may join and participate on the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives or guardians. The information may be used for diagnosis, therapy, follow-up and/or education.
TeleMed requires transmission, via internet or tele-communication device, of health information, which may include:

• Progress reports, assessments, or other intervention-related documents
• Bio-physiological data transmitted electronically
• Videos, pictures, text messages, audio and any digital form of data

The laws that protect the privacy and confidentiality of health and care information also apply to TeleMed. Information obtained during TeleMed that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations. By 
agreeing to use the TeleMed services, I am consenting to Hayes Clinic & Spa sharing of my protected health information with certain third parties as more fully described in the Hayes Clinic & Spa’s Privacy Policy. I understand, agree, and expressly consent to Hayes Clinic & Spa obtaining, using, storing, and 
disseminating to necessary third parties, information about me, including my image, as necessary to provide the TeleMed services.
As with any internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the TeleMed session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.
TeleMed sessions may not always be possible. Disruptions of signals or problems with the internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient or care team. I hereby release and hold harmless Hayes Clinic & Spa and all members of my care team from any loss of data or information due to technical failures associated with the TeleMed service.
I understand and agree that the health information I provide at the time of my TeleMed service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my TeleMed visit, and that such professionals may not have 
access to my full medical record or information held at Hayes Clinic & Spa.
I understand that I will be given information about test(s), treatment(s), and procedure(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the TeleMed visit. I have the right to withhold or withdraw consent to the use of TeleMed services at any time and revert to traditional in-person clinic services. I understand that if I withdraw my consent for TeleMed services, it will not affect any future services or care benefits to which I am entitled. All my questions have been answered to my satisfaction. I hereby consent to the use of TeleMed services in the provision of care and the above terms and conditions. By electronically signing, I certify that I am the legal representative of the participant of that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.
DISCLAIMER: By electronically signing, I certify that I am the legal representative of the participant of that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the consent form statements. I have read the Hayes Clinic & Spa TeleMed Informed Consent form. I have had all my questions answered. I understand that this informed consent will become a part of my medical record. By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.