Telemedicine Informed Consent


Telemedicine 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.
The information may be used for diagnosis, therapy, follow -up and/or education, and may include
any of the following:

= Patient medical records
= Medical images
= Live two-way audio and video
= Output data from medical devices and sound and video files

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.

Expected Benefits:

=  Improved access to medical care by enabling a patient to remain in his/her ophthalmologist’s
office (or at a remote site) while the physician obtains test results and consults from healthcare
practitioners at distant/other sites.

= More efficient medical evaluation and management.

= Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine.
These risks include, but may not be limited to:

= In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to
allow for appropriate medical decision making by the physician and consultant(s);

= Delays in medical evaluation and treatment could occur due to deficiencies or failures of the

= In very rare instances, security protocols could fail, causing a breach 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;

Informed Consent for Telemedicine

By agreeing to this form, I understand the following:

1.  I understand that the laws that protect privacy and the confidentiality of medical information
also apply to telemedicine, and that no information obtained in the use of telemedicine which
identifies me will be disclosed to researchers or other entities without my consent.

2.  I understand that I have the right to withhold or withdraw my consent to the use of
telemedicine in the course of my care at any time, without affecting my right to future care or

3.  I understand that I have the right to inspect all information obtained and recorded in the
course of a telemedicine interaction, and may receive copies of this information for a
reasonable fee.

4.  I understand that 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 ophthalmologist has explained the
alternatives to my satisfaction.

5.  I understand that telemedicine may involve electronic communication of my personal medical
information to other medical practitioners who may be located in other areas, including out of

6.  I understand that it is my duty to inform my ophthalmologist of electronic interactions
regarding my care that I may have with other healthcare providers.

7.  I understand that I may expect the anticipated benefits from the use of telemedicine in my
care, but that no results can be guaranteed or assured.