Dear Patient / Authorized Representative:

PLEASE READ THIS FORM CAREFULLY.

• Talk to your healthcare provider regarding any concern or question you may have.

• You may opt, at any time, to withhold this informed consent form.

1. Purpose and Benefits.
Teleconsultation will enable patients to get medical consultation by specialists without the health risk, and inconvenience. With teleconsultation, patients will receive continuous and convenient care, guidance on monitoring their condition and addressing changes to their condition, medication management and instructions on laboratory and imaging tests.

2. Nature of Teleconsultation.
During the teleconsultation:

a. Consent to processing of personal information and authentication of the patient’s identity will take place prior to the start of the teleconsultation

b. Details of the patient’s medical history, examinations, imaging, and laboratory tests will be discussed with the healthcare provider through interactive video, audio, and other telecommunication technology

c. The patient may be asked to show certain body parts or perform appropriate activities as may be considered important to form a diagnosis. This is in view of the fact that the healthcare provider will not be in the same room and would not be able to perform the necessary physical examination.

d. A non-medical technician may be present in the teleconsultation studio to aid in the video transmission

e. Video, audio, and/or photo recordings may be taken during the procedure(s) or service(s)

3. Confidentiality and Data Security.
Reasonable and appropriate efforts have been made to mitigate/eliminate any risks associated with the teleconsultation. All existing protections under local laws apply to information disclosed during this teleconsultation as well as access to medical information and copies of the medical records.

Additionally, dissemination of any patient-identifiable images or information from this teleconsultation interaction to researchers or other entities shall not occur without your consent and unless authorized under existing confidentiality laws.

4. Possible Risks.
 The teleconsultation uses interactive video technology to allow you to communicate with your healthcare provider from your home. There are potential risks associated with the use of teleconsult, such as but is not limited to:

a. The use of video technology to deliver healthcare and educational services may not be equivalent to direct patient to healthcare provider contact.

b. The information transmitted may not be sufficient (e.g. poor resolution of images or video/audio) to allow for appropriate medical decision-making by the healthcare provider(s).

c. Delays/differences in medical evaluation and treatment can occur due to the restrictions/limitations of the technology/equipment.

d. While all consultations are confidential, given the nature of digital technology and despite using appropriate measures, security protocols may fail causing breach of privacy and illegal access. All parties shall assume the risks of data loss, corruption, destruction or interception or the illegal use of such data arising from breach in security.

5. Patient Rights.
The patient has the right to:

a. Withhold or withdraw consent to the teleconsultation at any time without affecting his/her right of future care or treatment, or risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled.

b. Consult with a healthcare provider in person.

c. Ask non-medical staff to leave the teleconsultation room.

d. Obtain a copy of the information obtained and recorded during the teleconsultation.

e. Be assisted by a family member or caregiver in the set-up of the teleconsultation at home and to answer some questions.

By my consent, I confirm that:

1. I have read or have had this form read and explained to me, all my questions have been answered to my satisfaction, and I understand all the information given regarding teleconsultation;

2. All information that I will provide during the teleconsultation are true and correct. I understand that any incorrect or insufficient information may result to an incorrect or insufficient plan of care and/or diagnosis.

3. For the teleconsultation to work effectively, I must do my part in this two-way process. I will confirm my appointment and be available at the time agreed upon. I will advise the healthcare provider on any cancellation or postponement of the appointment at least one hour ahead and will expect the same from them when circumstances warrant.

4. I agree not to record the consultation in video, audio, or other format for any purpose without the consent of any of my healthcare providers nor will I divulge the details of my consultation in compliance with the Data Privacy Act of 2012 and other privacy related laws.

5. I will seek consent of my healthcare provider should a companion be necessary to sit in during the teleconsultation.

6. If there is a need for evaluation which requires my physical presence, the conduct of the session will either be terminated or still proceed but I may be asked to visit the hospital for further evaluation or submit other requirements that my healthcare provider may recommend.

7. I understand that either my healthcare provider or I can discontinue the consultation if the video conferencing connection is unstable. In such case, my healthcare provider and I may resume the call via another authorized video conferencing utility or reschedule the session.

8. I agree to the sharing of my personal and necessary health information to members of my healthcare team for comprehensive and collaborative care, with my health maintenance organization for the processing of my claims, if applicable, and with the clinic or hospital staff of my healthcare provider to facilitate scheduling of my consultation and for billing purposes.

9. While the institution has placed appropriate security measures to protect the privacy of my personal and health information, I am aware that potential risks and threats to digital technology may still occur outside the control of Pulmo Clinic. I understand the implications of this service when it comes to my data and will not hold the institution accountable.