Telemedicine Consent

By using the Website or by clicking to accept or agree to the Terms of Use when this option is made available to you, you accept and agree to be bound and abide by this Telehealth Consent Form and our Privacy Policy, incorporated herein by reference.

Understanding Telemedicine Services

I understand that receiving services using telehealth/telemedicine is not the same as an in-person visit because I will not be in the same physical location as my clinical team. When receiving telehealth/telemedicine services, potential risks include, but are not limited to, the clinician's inability to make clinical observations or identify potential issues that may be more observant through in-person visits.

I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held at Greenlight Neurology.

I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.

Right to Withdraw Consent

I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time, including during a telehealth/telemedicine visit, and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled. All my questions have been answered to my satisfaction.

I understand that my Greenlight Neurology clinician may determine in his or her sole discretion that my condition is not suitable for treatment using the telehealth/telemedicine services, and that I may need to seek medical care and treatment from an alternative source.

What is Telehealth/Telemedicine?

Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants and other healthcare providers who are part of my clinical care team.

In addition to myself and the members of my clinical care team, my family members, caregivers, or other legal representatives or guardians may join and participate in my telehealth/telemedicine sessions upon my request. To the extent another individual participates in my telehealth/telemedicine session, I acknowledge that such individual will have access to the personal information that is discussed, and I agree to share such personal information with the participating individual. The information may be used for diagnosis, therapy, follow-up and/or education.

Information Transmitted

Telehealth/Telemedicine requires transmission, via Internet or telecommunication device, of health information, which may include:

• Progress reports, assessments, or other intervention-related documents
• Bio-physiological data transmitted electronically
• Videos, pictures, text messages, audio and any digital form of data

Privacy and Confidentiality

The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except in accordance with applicable law, including for the purposes of treatment, payment, and healthcare operations.

By agreeing to use the telehealth/telemedicine services, I am consenting to Konstantin Karmazin, M.D. PLLC ("Greenlight Neurology") sharing of my protected health information with certain third parties as more fully described in Greenlight Neurology's HIPAA Notice of Privacy Practice. I understand, agree, and expressly consent to Greenlight Neurology obtaining, using, storing, and disseminating to third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.

Security and Technical Considerations

As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used will incorporate network and software security protocols that are designed to protect the confidentiality of patient identification and imaging data and will include measures designed to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. I further understand that I will be informed of their presence, and I have a right to object to their presence. This is so they can operate or repair the video or audio equipment used. These persons will be bound by applicable privacy and security requirements.

Technical Limitations

Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet's infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that could delay or prevent effective interaction between consulting clinician(s), participant, patient or care team.

I hereby release and hold harmless Greenlight Neurology and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.

I further understand that the use of telehealth/telemedicine communications may provide potential benefits to me, including increased access to care, but as with any clinical service, no clinical benefits or specific results can be guaranteed.

Consent

I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.

I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understood the above statements.

Contact Us

If you have any questions or objections to this form, please contact us at:

Greenlight Neurology
4500 9th Ave NE, Ste 300
Seattle, WA 98105
Email: contact@greenlightneurology.com