Telemedicine Consent Form
- I authorize Beverly D. Kindblade, MS, RDN, CD, Seattle Nutrition and Beve Kindblade Consulting to allow me/the patient to participate in a telemedicine (videoconferencing and phone) service.
- The type of service to be provided by via telemedicine is under the specialty of Nutrition Counseling and Medical Nutrition Therapy.
- I understand that this service is not the same as a direct patient/healthcare provider visit because I/the patient will not be in the same room as the healthcare provider performing the service.
- Beverly D. Kindblade, MS, RDN, CD has fully explained to me the nature and purpose of the videoconferencing technology and has also informed me that our sessions will be HIPAA-compliant to protect my healthcare privacy.
- I understand this technology may include interruptions and/or technical difficulties depending on the connection between my internet service provider (ISP) and the company providing the internet service by my healthcare provider. I am aware that either my/the patient’s healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation.
- I understand that the telemedicine session will not be audio or video recorded at any time.
- I agree to permit my/the patient’s healthcare information to be shared with other individuals for the purpose of scheduling appointments and billing claims to my healthcare insurance company.
- I acknowledge that I have the right to request the following:
- Omission of specific details of my/the patient’s medical history/physical examination that are personally sensitive, or
- Termination of the service at any time.
- It is the responsibility of the telemedicine provider, Beverly D. Kindblade, MS, RDN, CD, to conclude the service and terminate the videoconference connection.
- I/the patient understand(s) that my/the patient’s insurance will be billed by Beverly D. Kindblade, MS, RDN, CD as the telemedicine healthcare provider for telemedicine services. I/the patient understand(s) that if my insurance does not cover telemedicine services I/the patient will be billed directly by Beverly D. Kindblade, MS, RDN, CD for the provision of telemedicine services.
- My/the patient’s consent to participate in this telemedicine service shall remain in effect for the duration of the specific service identified above, or until I revoke my consent in writing.
- I/the patient agree that there have been no guarantees or assurances made about the results of this healthcare service.
- I confirm that I have read and fully understand this Telemedicine Consent Form. All blank spaces have been completed prior to signing. I have crossed out any words or paragraphs in this form which do not pertain to me.
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