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Informed Consent for Telehealth Visit

I hereby consent to receiving treatment through telehealth from my Cedars-Sinai Health System provider or a qualified member of his or her care team. I understand that "telehealth" is the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care. I understand that telehealth also involves the communication of my medical information, both orally and visually, to health care providers located at Cedars-Sinai affiliated facilities or elsewhere.

I understand that I have the following rights with respect to telehealth:

(1)  I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. I understand that receiving treatment through telehealth does not mean I cannot receive in-person health care services, either today or in the future. I understand that there are limitations to the types of treatment that can be appropriately provided via telehealth, and that my provider determines whether or not it is appropriate for me to receive treatment via telehealth.

(2)  The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to reporting child, elder, and depending adult abuse, expressed threats of violence towards an ascertainable victim, and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

(3)  I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured. I also understand that there are risks involved in receiving treatment via telehealth, such as interruption of the audio-video connection between me and my provider, or delays in receiving medical treatment because of technological failures.

(4)  I understand that I have a right to access my medical information and copies of medical records in accordance with California and federal law.

I understand that I can discuss any questions that I have with my provider at the beginning of my telehealth consult, that my provider will answer any such questions, and that I may decline to continue the telehealth consultation at any time.

By beginning my telehealth consult, I confirm that I have read and understand the information in this Informed Consent, and give my informed consent to receive treatment via telehealth.