I give my consent to be interviewed by the consulting health care provider. I also understand other individuals may be present to operate the video equipment and that they will take reasonable steps to maintain confidentiality of the information obtained.
I understand that a limited physical examination will take place during the videoconference and that I have the right to ask my healthcare provider to discontinue the conference at any time.
I authorize the release of any relevant medical information about me to the consulting health care provider, any staff the consulting health care provider supervises, third party payers and other providers who may need this information for continuing care purposes.
I hereby release Florida Diabetes and Endocrine Associates, its personnel and any other person participating in my care from any and all liability which may arise from the taking of video recordings/digital films and photographs and I understand that the dissemination of any identifiable images/recordings will not occur without my consent.
I will not record any telemedicine sessions without the written consent from my provider.
I understand that my provider will not record any of my telemedicine sessions without my written consent.
My telemedicine session will be conducted in a private area. I will notify my provider if any other persons can hear or see the telemedicine session.
I understand that I will be responsible for any copayments, co-insurances or deductibles that apply to my telemedicine visit.
I understand that if my insurance does not pay for my initial consultation, I will pay $75 flat rate for the initial consultation fee.