Telehealth Policy

PCOS Sisters Telehealth Clinic & Wellness Center

CONSENT FOR TELEHEALTH CONSULTATION WITH AUTONOMOUS NURSE PRACTITIONER IN FLORIDA & NEW YORK. SUPERVISION BY MD IN GEORGIA & TEXAS.

1. I understand that I am voluntarily engaging in a telemedicine consultation with PCOS Sisters Telehealth Clinic & Wellness Center providers, which may include Autonomous Advanced Practice Registered Nurses defined by Florida law as an Advanced Practice Registered Nurse who practices independently without supervision of a physician, only engaging in primary care practice – includes physical and mental health promotion, assessment, evaluation, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses, inclusive of behavioral and mental health conditions.
2. If located in Georgia or Texas, Advanced Practice Registered Nurses are required to be supervised by a Georgia or Texas licensed MD. In this case, Dr. Rita Beckford, MD.
3. I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
4. I understand that I must be physically located in the state in which my provider is licensed at time of visit. If I am not located in a state matching my provider’s state license at the time of visit, I understand that my appointment will be canceled and I will be charged a $25 no show fee. 
5. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.
6. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
8. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with PCOS Sisters Telehealth Clinic & Wellness Center and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.
9. I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through PCOS Sisters Telehealth Clinic & Wellness Center will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.
10. Telemedicine services offered through PCOS Sisters Telehealth Clinic & Wellness Center are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.
11. To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.
12. It is recommended that patients receive an in-person physical exam at least annually by a licensed medical provider. If you do not have a medical provider that can provide a physical exam annually, PCOS Sisters Telehealth Clinic & Wellness Center will refer you to a local medical provider upon request.

By signing this form, I certify:

• That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.
• That I have had the opportunity to ask questions and have had them answered to my satisfaction.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.