Telehealth Informed Consent – Physician360
Physician360
3379 Peachtree Road NE, Suite 700
Atlanta, GA 30326
Phone: (360) 861-6199
Fax: (360) 282-0136
info@myphysician360.com
myphysician360™ Telehealth Consent & Informed Agreement
Telehealth involves the delivery of healthcare services using secure electronic communications, including live video, audio, messaging, and review of medical information. Through myphysician360.com, I may receive care from licensed healthcare providers using the Physician360 telehealth platform.
I understand that telehealth allows me to consult with my provider remotely and does not replace my relationship with my primary care provider or other local healthcare professionals. Day-to-day responsibility for my healthcare should remain with my local provider, if I have one.
How Telehealth May Be Used
Telehealth services may include, but are not limited to:
- Live two-way video or audio consultations
- Review of my medical history, records, images, or diagnostic information
- Follow-up care, education, and treatment recommendations
Potential Benefits
- Improved access to medical care
- Reduced travel time and delays in treatment
- Ability to consult with specialists remotely
Potential Risks and Limitations
I understand that:
- Telehealth may not be appropriate for all medical conditions.
- My provider may determine that in-person care, urgent care, or emergency services are necessary.
- Technical difficulties may occur that could interrupt or delay care.
- Limitations in available information may affect clinical decision-making.
Privacy and Confidentiality
I understand that laws protecting the privacy and confidentiality of medical information apply to telehealth services. myphysician360™ uses reasonable administrative, technical, and physical safeguards to protect my personal health information in compliance with HIPAA. While every effort is made to protect my information, I acknowledge that electronic communications carry inherent risks and absolute confidentiality cannot be guaranteed.
Consent to Treatment and Use of Information
I consent to receive healthcare services via telehealth and authorize myphysician360™ to use and disclose my protected health information as necessary for treatment, payment, healthcare operations, and as otherwise permitted by law.
Additional Acknowledgments
Telehealth providers may be located in a different city or state than I am.
I may withhold or withdraw my consent to telehealth services at any time without affecting my right to future care.
No specific results or outcomes can be guaranteed.
By proceeding and creating an account or logging in, I confirm that I have read and understand this document, have had my questions answered, and voluntarily consent to participate in telehealth services provided through myphysician360™. Further, you are agreeing with Physician360’s HIPAA Notice of Privacy Practices.
