Telemedicine Authorization and Consent

Please review and agree using the consent form below before your telemedicine visit. 

Information about telemedicine

  • Your provider may talk to you about your health history, exams, x-rays, or other tests. Other providers may take part.
  • Non-medical staff may be in the room to help with the technology.
  • Video and/or photo records may be taken, and audio recordings may be made.
  • A report of the session will be placed in your doctor’s medical record. You can get a copy from your doctor.
  • All laws about the privacy of your health information and medical records apply to telemedicine. These laws also apply to the video, photo, and audio files that are made and stored.
  •  It may be hard to diagnose your problem without a “hands-on” exam.
  • A main goal of telemedicine is to make sure you get high quality, personal health care, even though you are not seeing a provider in person.
  • Having a telemedicine session is your choice. Even if you have agreed to the session, you can stop your medical records from being sent – if this has not happened yet. You can refuse or stop the session at any time.
  • You’ll be told about all staff that will take part in the session. You can ask that any of these people leave the room and stop them from seeing or hearing the session.
  • Your session may end before all problems are known or treated. It is up to you to follow up for more care if your health problem does not go away.
  • You may ask how much of the cost will be covered by insurance and how much you may owe before your session.

Risks and common problems

  • Equipment or Internet problems could cause your diagnosis or treatment to be delayed.
  • The records sent for review before the session may not be complete.  It may be hard for the telemedicine provider to use his or her best judgment about your health problem. For instance, you could react to a drug or have an allergic response if the provider does not have all the information that he or she needs.
  • If there is a technology problem, the information from your session may be lost. This would be outside the control of your doctor and telemedicine provider.
I confirm that:  I have been able to ask questions about telemedicine sessions, all my questions have been answered, and I would like to take part in a telemedicine session.  I have read, understand, and agree with the terms of NRGI\'s telemedicine policy.