Telehealth Consent

•I understand that my telemedicine encounter will be submitted to insurance (if applicable), and I will be responsible for any copayments or coinsurances that apply.

•I understand that telemedicine is the use of electronic information and communication by a Dr. Beasley to deliver services to an individual when he/she is located at a different location or site.

• I understand that the telemedicine visit will be done through a two-way video link-up. Dr. Beasley and clinical staff will be able to see my image on the screen and hear my voice. I will be able to hear and see Dr. Beasley.

• I understand that the laws that protect privacy and the confidentiality of medical information including (HIPPA) also apply to telemedicine.

• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without effecting my right to future care or treatment.

•By proceeding with the Telehealth Encounter, I am consenting to the terms above.