DERMATOLOGIC SERVICES
Telehealth Consent Form

DERMATOLOGIC SERVICES 

Telehealth Consent Form 

Last Updated: August, 2022 

Please read the following information carefully, as it will outline the basics of telehealth as well as  how you will receive evaluation or treatment via telehealth if you consent to participate. Signing  this form represents a binding agreement between yourself and Dermatologic Services regarding  the use of telehealth for evaluation and/or treatment and represents that you understand and  agree to the following:  

1. Purpose.  

The purpose of this form is to explain the telehealth services that may be provided by  Dermatologic Services. Dermatologic Services can provide dermatology services via telehealth to diagnose and treat acne, rosacea, hypotrichosis, androgenic alopecia, skin aging,  pseudofolliculitis barbae, and seborrheic hyperpigmentation. The telehealth services that  Dermatologic Services provides can include patient assessment, diagnosis, consultation,  treatment, education, care management and/or self-management.  

2. How Telehealth Works.  

Telehealth involves the use of electronic communications to provide healthcare services remotely through electronic information and communication technologies while your provider, the  dermatologist and you, the patient, are in two different locations. By signing this form, you are  acknowledging that you are located in New York and will be receiving such services in New York. 

Telehealth is not an appropriate substitute in some cases for in-person treatment or advice from  your primary care physician or other qualified healthcare professional. Dermatologic Services will  notify you if telehealth is appropriate to treat your condition.  

In a telehealth visit, you will send health information and photos to your Dermatologic Services  provider via our secure, online platform. This provider has the right to discontinue or not provide  services should the information you provide be incomplete or the photos you send be of poor  quality. Additionally, the severity or complexity of some skin conditions are not appropriate for  telehealth. You may be required to make an in-person appointment for further evaluation should  this occur. Dermatologic Services does not offer in-person appointments with providers at this  time, so you will have to seek your care elsewhere if this is the case. If you do not have another  provider that you wish to see for your condition, your Dermatologic Services provider will provide  you with a list of appropriate providers in your area.  

Your Dermatologic Services provider, in their sole discretion, will determine whether or not your  condition is suitable for telehealth. After you have submitted an initial intake form and participated  in a consultation, the provider will review your medical history and photos. If the provider believes you are an appropriate candidate for telehealth, the provider will then give you advice about your  dermatologic condition and how to treat and take care of your condition. 

3. Pros, Cons and Your Options.  

There are both benefits as well as risks when using telehealth for treatment or evaluation. The  benefits of telehealth include but are not limited to, a more convenient way for a patient to receive  treatment or evaluation from a provider. The risks of using telehealth for treatment or evaluation  include but are not limited to, disruption of transmission, technology failures, breaches of  confidentiality by unauthorized individuals, and a limited ability to respond to an emergency.  Additionally, with telehealth, a dermatology provider will advise you based on your initial intake  form, consultation, a review of your medical history, and the photos that you have provided. The  provider’s advice will and only can be solely based on the information and photos provided. In  the absence of an in-person physical evaluation, the provider may not be aware of certain facts  that may limit or affect his or her assessment or diagnosis of your condition and recommended  treatment. It is possible that there will be deficiencies in the provided information and photos that  may impede the provider’s ability to advise you about your condition. By signing this form, you  acknowledge that you understand that the telehealth sessions differ from being in the office with  your provider because you will not be in the same room.  

4. Presence of Others During Telehealth Visit and Recording.  

Members of the telehealth team from Dermatologic Services, other than your provider may be a  part of your care and will have as needed access to your medical history and photos. Anyone  that is a part of the telehealth team will be supervised by the provider, and the final  recommendations about your care will come from the provider and will be made by the provider  using their independent professional judgement. 

When receiving services via telehealth, it is your responsibility to ensure that you are in a private  location where others cannot hear the appointment, in order to maintain the privacy of your health  information. Aside from the above-mentioned telehealth team that will be involved as needed,  your provider will also conduct the telehealth session in a location conducive to keeping health  information private and maintaining professional guidelines. 

Telehealth sessions will not be recorded by either party.  

5. Medical Information and Records.  

Any information that Dermatologic Services needs to provide to you when conducting treatment  or evaluation via telehealth will be provided either securely through electronic means or through  the physical mail. All federal and state laws regarding access to your medical records (and copies  of medical records) also apply to telehealth. Information obtained through telehealth will be kept  confidential and will not be given to anyone without your valid written consent, except where such  disclosure is required by law or an exception to confidentiality applies.  

6. Privacy and Security.  

The technology that will be used by this practice is G Suite. This technology is compliant with  requirements regarding the privacy and security of your health information in accordance with  both the federal Health Insurance Portability and Accountability Act (“HIPAA”) regulations as well  as New York State Privacy laws and all other applicable federal and state privacy laws. 

As with any Internet-based communication, as mentioned above, there is a risk of security breach.  All electronic systems used will incorporate network and software security protocols to protect the  confidentiality of patient identification and imaging data. This will include measures to safeguard  data and ensure its integrity against intentional and/or unintentional corruption.  

7. Your Rights.  

You may withhold or withdraw your consent to the use of telehealth services at any time in which  case you will discuss with your provider alternative services such as seeing your primary care  provider or another dermatologist since Dermatologic Services does not currently provide in person treatment or evaluation. As mentioned above, Dermatologic Services will provide you with  a list of appropriate providers in your area. . This will not change your right to future care or health  benefits.  

8. Emergency. 

In the event of an emergency during a telehealth session, your provider will contact the  appropriate emergency services as well as your emergency contact that Dermatologic Services  has on file.  

9. Acknowledgement.  

You understand and agree that you solely assume the risk of any errors or deficiencies during  your telehealth visit due to the information and photos that you provide as stated in paragraph  three (3) above. The consent provided in this document will expire one (1) year from the date of  signature below, but your waiver and release shall apply indefinitely for any telehealth visits that  occur during the one (1)year period after your signature date.  

By signing below, you certify that you are the patient or legal representative of the participant and  that you are 18 years of age or older. You have carefully read and understand the above  statements and that this informed consent will become a part of your medical record. 

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Full name (Printed)  

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Signature  

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Date