Patient Consent Form for Medical Services

I authorize QUICKHEALTHDOCTORS’s medical professionals to provide me with their observations and recommendations regarding my medical condition and potential courses of action, using telemedicine. The use of telemedicine involves the electronic communication of my medical information. I understand that QUICKHEALTHDOCTORS is a Telehealth Technology Provider and its medical professionals will perform an in-person physical examination during the telemedicine consult as required. They will rely solely on the information telecommunicated. I authorize the QUICKHEALTHDOCTORS to consult with any other physician specialists whom they may choose to involve in my case if necessary. I understand that I have the following rights with respect to the telemedicine services performed by QUICKHEALTHDOCTORS: Confidentiality. The laws that protect the confidentiality of medical information apply to telemedicine and no information or images from the telemedicine interaction which identifies me will be disclosed to other parties without my consent, except as permitted by law. Access to information. I have the right to inspect all medical information transmitted during QUICKHEALTHDOCTORS’s telemedicine consultation and may receive copies of this information for a reasonable fee. Right to withdraw.I have the right to withhold or withdraw my consent to telemedicine at any time, without affecting my future right to health care or treatment and without risking the loss of my health coverage. I understand that there are risks from telemedicine, including but not limited to: loss of records from the failure of electronic equipment; power failure with loss of communication; and invasion of electronic records from outsiders (hackers). In addition, signs and symptoms that might be detected during an in-person physical examination may not be detected through telemedicine. I understand that I have the option of seeing another physician on a face to face basis who could provide me with observations and recommendations. I warrant that the QUICKHEALTHDOCTORS medical professionals/physician observations and recommendations are limited in scope and nature to the specific issues discussed during the telemedicine consult. I have read and understood the information provided above. I agree and all my questions have been answered to my satisfaction. I consent to receive the telemedicine services described above.