Telemedicine Informed Consent


Effective March 23, 2020

Please do not use telemedicine/telehealth for emergency medical needs. 

If you experience a medical emergency, call 911 immediately!


You acknowledge that you are consenting to receiving care via telemedicine/telehealth. The scope of care will be at the sole discretion of the Belleville Dermatology Center, with no guarantee of diagnosis, treatment or prescription.  Dr. Eastern and/or such assistants or employees as may be selected by him will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter. You understand and agree that your interaction is not intended to take the place of any face-to-face appointments, when possible.

The Belleville Dermatology Center is dedicated to maintaining the privacy of your protected health information (“PHI”). PHI is information about you that may be used to identify you, including but not limited to your name, address, health insurance identification number, date of birth, and information that relates to (a) your health or condition, (b) healthcare provided to you, or (c) payment for healthcare provided to you. In conducting its business, the Belleville Dermatology Center will receive and create records containing your PHI. The Belleville Dermatology Center is required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. 

The Belleville Dermatology Center must abide by the terms of this Notice while it is in effect. This current Notice takes effect on the date that it is signed and will remain in effect until Belleville Dermatology Center replaces it. The Belleville Dermatology Center reserves the right to modify or change the terms of this Notice at any time. If the terms of this Notice are modified or changed, the new terms will apply to all PHI that it maintains, including PHI that was created or received before the changes or modifications were made. The Notice will be available upon request. 

Informed Consent For Services Performed Via Telemedicine/Telehealth

The delivery of healthcare through services using communication tools such as a cell/telephone, live two-way audio and video, remote patient monitoring, or other electronic means, is called “telemedicine”. Telemedicine involves the use of electronic communications to enable healthcare providers who are remote from patients to provide care and services. The information gathered/accessed may be used for diagnosis, treatment, follow-up, therapy or education and may include information from existing medical history or records.

The communication systems used will incorporate network and software security protocols to protect your confidentiality and will include measures to secure the data against intentionally/unintentional corruptions or access. It is your responsibility to be in a secure/private location where your telemedicine/telehealth encounter can occur. Do not use telemedicine/telehealth services in a public location, or on a public computer where you can be overheard or others can see your personal information.

As with office-based face-to-face visits, a visit summary will be made available to you if you request. This summary can be kept for your records or shared with another healthcare provider of your choosing (e.g., specialist or other provider).

Benefits of Telemedicine

  • Improved and increased access to care remotely.
  • More efficient medical evaluation and management.
  • Convenience.

Possible Risks of Telemedicine

As with any medical visit, office based or otherwise, there are potential risks associated. The risks may include:

  • Delays in medical evaluation and consultation or treatment due to deficiencies or failure of technology;
  • In very rare instances, unanticipated breach in security protocols e.g., poor security controls. You have the right to be notified in the event that the Belleville Dermatology Center discovers a breach of unsecured PHI;
  • In rare cases, a lack of access to complete or comprehensive medical records, resulting in adverse drug interaction, allergic reactions or other negative outcomes;
    • Patient must disclose accurate, comprehensive/complete medical and medication history.

How To Receive Follow up Care

If at any time during the telehealth visit:

  • You experience a health emergency and feel you need immediate care, it may be necessary to call 911, or you may be directed to the nearest hospital/emergency room.
  • You or your healthcare provider may experience telecommunication or equipment failure that prohibits the completion of visit, immediately contact the office directly to be connected to afterhours call line and your healthcare provider.

By agreeing to these Terms of Use and by accepting Online Telemedicine/Telehealth Services you agree and understand the following:

  1. Your healthcare provider has the right to discontinue the visit at any time if he or she feels it is necessary, or if it is determined that an in-person visit is needed.
  2. The laws that protect privacy and confidentiality of medical information also apply to telemedicine/telehealth, and no information obtained in the use of telemedicine/telehealth that identifies you will be disclosed to researchers or other entities without your consent.
  3. You have the right to withhold or withdraw your consent to the use of telemedicine in the course of your care at any time, without affecting your right to future care or treatment.
  4. Telemedicine involves electronic communications of your personal health information.
  5. You agree to keep the Belleville Dermatology Center informed of any change in address, and agree to cooperate in your care.  Any disputes that arise will be resolved in accordance with the Federal Arbitration Act, not litigation.
  6. Your health information may be shared with other individuals for treatment, payment and healthcare purposes.
    1. Psychotherapy notes are maintained by the telemedicine healthcare clinician, but not shared with others. Only billing codes and visit summaries with be shared with others and you.
    2. If you obtain psychotherapy services, you understand that your therapist has the right to limit the information provided to you, if in the therapist’s professional judgment sharing the information with you would be harmful to you.
  7. Your healthcare information may be shared in the following circumstances:
    1. A valid court order is issued for medical records;
    2. Reporting suspected abuse, neglect or domestic violence;
    3. Preventing or reducing serious threats to anyone’s’ health or safety.
  8. You may complain to the Belleville Dermatology Center and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated.  The Belleville Dermatology Center will not retaliate against you for filing a complaint. If you have any concerns, please contact our office.
  9. You have the right to obtain a paper copy of this Notice from Belleville Dermatology at any time upon request. 
  10. You have the right to inspect and obtain a copy of your PHI. You must submit your request in writing by completing a HIPAA Authorization. There may be a fee for the cost of copying, mailing, labor and supplies, or as otherwise permissible by law. Belleville Dermatology may deny your request to inspect and/or copy your PHI in certain limited circumstances. In the event your request is denied you may request a review of the denial. 

Charges for Services

You understand and agree that you are ultimately responsible for all charges related to your telehealth visit, including those excluded or declined by your insurance coverage.  You agree to pay for all services provided, and you agree that the charges are valid and appropriate.

Patient Consent to the Use of Telemedicine

Having read and understood the information provided above regarding telemedicine and understand the risk and benefits of telemedicine, I agree to Terms of Use, and give my informed consent to the Belleville Dermatology to participate in a telemedicine healthcare visit in the course of my diagnosis and treatment.