Informed Consent for Telemedicine

A. Telemedicine Services.  I understand that my health care provider(s) have offered me the opportunity to utilize telemedicine services (“Telemedicine Services”) as part of my treatment at the H. Lee Moffitt Cancer Center and Research Institute Hospital, Inc. (“Moffitt”). I voluntarily authorize Moffitt and its physicians, advanced practice professionals, and other persons (such as colleagues, physicians-in-training, technical assistants, and other health care providers) (“Provider(s)”), to utilize Telemedicine Services as part of my treatment.  I understand that Telemedicine Services involve the use of electronic communication by way of remote written electronic communication and video conferencing in lieu of direct in-person patient/ Provider interaction.  I also understand that my health care information may be shared with individuals who are not my Providers for scheduling and billing purposes, as well for operating any equipment, including video equipment, utilized to provide Telemedicine Services.  Information gathered from me as part of the Telemedicine Services may be used for diagnosis, therapy, follow-up and/or education, and may include, without limitation, the following:

• Medical Records
• Medical Images
• Live Two-Way Audio and Video
• Output Data from Medical Devices and Sound and Video Files
• Electronic Communication

B. Confidentiality. I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telemedicine Services, and that no information obtained in my use of Telemedicine Services that identifies me will be disclosed to third parties without my consent. In the instance that I participate in an Educational Group appointment, I (the participant) acknowledge and agree that my name, image, and personal information will be shared with other participants should I choose to disclose that information during the session.  

I understand that the Telemedicine Services will utilize electronic systems that 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.

C. Risks: I understand that there are risks associated with Telemedicine Services, including, without limitation, those listed below and I agree that I have had an opportunity to ask questions about the risks:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by my Providers;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In rare instances, security protocols could fail causing a break of privacy of personal medical information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
• Other: ________________________________________________________________________________________

D. Expected Benefits: I understand that there are certain expected benefits to utilizing Telemedicine Services, which include, but are not limited to, those listed below and I agree that I have had an opportunity to ask questions about the benefits:

• Remote access to medical care by enabling me to initiate a visit and consult with my Provider at a distant/other site.
• More convenient medical evaluation and management.
• Ability to obtain the expertise of a distant specialist.

E. Consent to Telemedicine Services. I agree that the use of Telemedicine Services has been explained to me, including the purpose, anticipated benefits, anticipated duration, reasonable alternatives, the option of not utilizing Telemedicine Services, and the risks of not utilizing Telemedicine Services.  I have had the opportunity to ask questions, and all my questions have been answered. I voluntarily consent to utilizing the Telemedicine Services as part of my care at Moffitt.  By agreeing to this form and the use of Telemedicine Services, I understand the following:

• I have the right to withhold or withdraw my consent to the use of Telemedicine Services in the course of my care at any time, without affecting my right to future care or treatment.
• I have the right to inspect all information obtained and recorded in the course of Telemedicine Services, and may receive copies of this information for a reasonable fee.
• A variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.  My Provider has explained the alternatives to my satisfaction.>
• Telemedicine Services may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
• It is my duty to inform my Provider(s) of electronic interactions regarding my care that I may have with other health care providers.
• My Provider or I may discontinue the Telemedicine Services if it is felt that the videoconferencing connections are not adequate for the situation.
• In an emergent consultation, my Provider may refer me to my local practitioner and that my Provider’s responsibility will conclude upon the termination of the remote connection.

F. No Guarantee: I understand that the use of Telemedicine Services is not an exact science and I acknowledge that no warranty or guarantee has been made to me about the use of Telemedicine Services.

G. Photography: I authorize that photographs, videotapings, digital images, audiotapings, filmings, recordings and other visual and audio means may be taken of me during Telemedicine Services for: (i) treatment, identification, and diagnosis purposes; and (ii) educational purposes following the removal of any information or images that may identify me. I understand and agree that I am not permitted to utilize cameras, audio recorders, or any other recording devices to record my treatment and care.

H. Providers: I understand that Providers have been granted the privilege of using Moffitt’s facilities, but exercise their own independent medical judgment, are not under the control or supervision of Moffitt, and may be employees of the University of South Florida, Moffitt Medical Group, or other independent contractors of Moffitt and not employees or agents of Moffitt.