When scheduling a telemedicine consult, members agree to the following:

A telemedicine service means that health care services are provided by physicians and other practitioners at a distant location from the patient using interactive video and/or audio conferencing in real time with the aid of exchanged digital images of my health care data by an asynchronous means.

I also understand that:

• I may have to travel to see a health care provider in–person for certain diagnosis and treatment matters.
• The same confidentiality and privacy protections that apply to my other health care services also apply to these telemedicine services.
• I have access to all of my health and wellness information pertaining to the telemedicine services in accordance with applicable laws and regulations.
• I may need to see an appropriately trained health care professional in-person immediately after the telemedicine service if an urgent need arises.
• My health care information may be shared with other individuals for treatment, payment and health care operations purposes.

The scope of care will be at the sole discretion of the health care professional treating me, with no guarantee of diagnosis, treatment, or prescription. The health care professional will determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine exam.

I have read this document carefully, and all my questions were answered to my satisfaction. By acknowledging this, I confirm my review and consent to participate in the telemedicine exam.

I also acknowledge that HIPAA Notice of Privacy Practices was made available to me, and agree and authorize my health care professional to release information regarding the telemedicine exam to Telemedicine Management, Inc. and its affiliates.