Informed Consent for Telemedicine Health Services

Akenta Health, INC.

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I hereby consent to telemedicine as part of my participation in the digital cardiovascular platform offered through Akenta Health Inc.’s (“Company”) website, mobile application (collectively “the Platform”). This informed consent covers one-to-one interaction with any provider who provides telemedicine services to me through the Platform. I understand that I will be receiving cardiovascular health services,  education and counseling through interactive audio, video, and other telecommunication technologies with a health professional who is not in the same physical location that I am to discuss my history, health information, and information related to my treatment.

 

Risks

Since my provider and I will not have direct face-to-face communication, there are certain risks: 

• Using telemedicine for cardiovascular health treatment for cardiovascular health services may have some limitations in comparison to in-person treatment.  For example, there is a risk that the quality of my telemedicine interaction or consultation will be diminished based on the difficulty of communicating and transmitting information without the benefit of being physically present, receiving non-verbal cues and the greater risk of distraction. My provider and I will see and hear each other electronically, but some information my provider may ordinarily get in-person will be unavailable. 

• There is a risk that, in the event of an emergency, I will be alone and without the benefit of in-person interaction to support me. 

• Despite Company’s best efforts to protect privacy and data security, there is a greater risk of intentional or unintentional violation of the confidentiality of patient information when transmitted electronically resulting in risks such as interception, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. 

• There is a risk of technology failure and interruption by a connectivity problem. I understand that I will need access to, and familiarity with, the appropriate, working technology in order to participate in the service provided by Company, with a risk of corruption or technology interruptions. 

• I am responsible to sign on at the right time and with the appropriate technology in an appropriate location for all scheduled appointments.

 

Benefits

• Telemedicine provides greater convenience and flexibility in receiving counseling and treatment. 

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Alternatives

• I have the right to decline to participate in telemedicine services at any time. 

• I have the right at any time to request an assessment of the appropriateness of services I am receiving and the technology being used.

 

Acknowledgment

• Company and my provider have explained how telemedicine treatment and consultation will differ from in-person services for my cardiovascular care. 

• I have had the opportunity to ask questions and receive answers to my satisfaction about using telemedicine in my treatment with Company and my provider. 

• I acknowledge and agree that if I am facing or if I think I may be facing an emergency situation that could result in harm to me, I will seek care immediately by dialing 911 or contacting the nearest hospital emergency department. 

• I can refuse to give consent or can withdraw consent, at any time, with written notification to the Company or my provider.  This will not affect my right to change my decision, at a later date. 

 

Based on the above, I certify that I have read the foregoing Informed Consent, had opportunities to ask questions, agree and accept all of the terms above, and voluntarily consent to participate in telemedicine for cardiovascular services, including but not limited to any care, treatment, and services deemed necessary and advisable by my provider.  I also specifically consent to the uses and disclosures of my health data necessitated by telemedicine, including videoconferencing, recording and storage of videoconferences, email, text messages, and other digital communications exchanged in the course of care.