Texas Telemedicine Consent Form

Please review the following terms

Texas laws define telemedicine as remote medical services provided to a patient by a physician who is licensed in Texas. With this, it should be noted that in order for the proper conduct of telemedicine, the physician must be within the vicinity of the state of Texas. This however requires that in the practice, the patient should also be within the state of Texas for the proper conduct of the service.

In order for the service of telemedicine to take place, please go through and understand each item in this informed consent form. If you have questions, please do not hesitate to let us know and we will be more than happy to answer them for you.

I voluntarily give my consent to engaging in telemedicine with the physician(s) for the purpose of treatment and diagnosis.

I understand that telemedicine involves the use of audio, video, and/or data communication for consultation, diagnosis, treatment, or education purposes.

I understand that telemedicine has its limitations and shall not be equal to a face-to-face consultation as the doctor cannot use the senses of touch or smell which may be needed during consultation and diagnosis, and that there is no assurance guaranteed to the benefits of telemedicine.

I understand that with telemedicine, communication interruptions may arise which may not be the fault of the doctor nor mine. I understand that this instance may cause delay or problems in communication that may prevent proper engagement.

I understand that I have the right to withhold or withdraw my consent from this telemedicine agreement and that such will not affect my right to further future care or treatment that of which I am entitled.

I understand the laws in place that protect my privacy and that such privacy and confidentiality, particularly relating to health, such as that of HIPAA, likewise apply in telemedicine. Any dissemination of information that may personally identify my person shall require my prior written consent.

I understand that these confidentiality rights are not absolute. Any matter that may involve abuse, harm, or violence towards a child, an elder, or any person shall permit the doctor to report to proper authorities if he or she believes the possibility of such an event to happen or may have happened.