Telehealth Patient Consent Form.

I, the undersigned patient or parent/legal guardian for the minor patient, agree to receive outpatient telehealth services.  I understand that the licensed health care practitioner, is located at an off site location, who is an employee of the Passion Care Center, Perth Amboy, NJ.  A telemedicine service means that the patient’s visit with a licensed health care practitioner at another location (distant site) will happen by using special audiovisual equipment.

*I, for myself or as the parent/legal guardian for the minor patient, also understand and agree that:

*I can decline the telehealth service at any time without affecting my right to future care or treatment, any program benefits to which I would otherwise be entitled cannot be taken away.

*If I decline the telehealth services, the other options and alternatives available to me, including in-person services, are as follows: to be seen at The Passion Care Center in Perth Amboy, NJ 08861.

*The same confidentiality protections that apply to my other medical care also apply to the telemedicine service.

*I will have access to all telemedicine information resulting from the telehealth service as provided by law.

*The information from the telehealth service (images that can be identified as mine or other medical information from the telehealth service) cannot be released to researchers or anyone else without my additional written consent.

*I will be informed of any individuals who will be present at the originating site (Perth Amboy, NJ 08861) and the distant site during my telehealth service.

*I may exclude anyone from any site during my telehealth service but acknowledge that if I choose to exclude the above-named health care practitioner from my telehealth service, The Passion Care Center may terminate the doctor or counselor patient or provider-patient relationship at that time.

*I understand that telemedicine requires me to have a secure connection to internet access. It is my responsibility to ensure that I am in a private area and will not hold The Passion Care Center responsible for information that may be found on any of my electronic devices. Additionally, if my session is interrupted due to power failure or a faulty connection I can call 732-410-7102 to re-establish connection or speak to a representative to reschedule

I have read this document carefully and understand everything within this document.