Patient Registration Form

Patient Information and Consent Form for Telemedicine and Bruce Semon, MD

Introduction

Telepsychiatry and telemedicine are the delivery of psychiatric and nutritional medical services using interactive audio and visual electronic systems where the doctor and the patient are not in the same physical location.

The interactive electronic systems used in telepsychiatry and telemedicine incorporate network and software security protocols (encryption) to protect the confidentiality of patient information and audio and visual data.

Potential benefits of telepsychiatry and telemedicinde

• Increased accessibility to psychiatric and nutritional medical care

• Patient convenience

Potential Risks with telemedicine

As with any medical procedure, there may be potential risks associated with the use of telemedicine

These risks include, but may not be limited to:

• Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate medical decision making by Dr Bruce Semon.

• Bruce Semon may not be able to provide medical treatment to me using interactive electronic equipment nor provide for or arrange for emergency care that I may require.

• Delays in medical evaluation and treatment may occur due to deficiencies or failures of the

• Security protocols can fail, (although extremely unlikely) causing a breach of privacy of my confidential medical information.

• A lack of access to all the information that might be available in a face to face visit but not in a telepsychiatry and telemedicine session may result in errors in medical judgment.

Alternatives to the use of telepsychiatry and telemedicine

• Traditional face to face sessions in Dr. Semon’s office

Confidentiality Standards required for telemedicine:

• During a telemedicine health session, both locations shall be considered a patient examination room regardless of a room’s intended use.

• Both sites shall be appropriately chosen to provide audio and visual privacy.

• Rooms shall be designated private for the duration of the session with the Doctor and no unauthorized access shall be permitted.

• Both sites shall take every precaution to ensure the privacy of the consult and the confidentiality of the patient. All persons in the exam room at both sites shall be identified to all participants prior to the consultation and the patient’s permission shall be obtained for any visitors or clinicians to be present during the session.

• HIPAA confidentiality requirements apply the same for telepsychiatry and telemedicine as for face-to-face consultations.

My Rights

• I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry.and telemedicine

• I understand that the video conferencing technology used by Dr. Semon is encrypted to prevent unauthorized access to my private medical information.

• I have the right to withhold or withdraw my consent to the use of telepsychiatry and telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.

• I understand that Dr. Semon has the right to withhold or withdraw his consent for the use of telepsychiatry and telemedicine during the course of my care at any time.

• I understand that the all rules and regulations which apply to the practice of medicine in the state of Wisconsin and California also apply to telepsychiatry and telemedicine

• I understand that Dr. Semon will not record any of our telepsychiatry and telemedicine sessions without my prior written consent.

My Responsibilities

• I will not record any telepsychiatry and telemedicine sessions without prior written consent from Dr. Semon.

• I will inform Dr. Semon if any other person can hear or see any part of our session before the session begins. Dr. Semon will inform me if any other person can hear or see any part of our session before the session begins.

• I understand that third-parties may be required to join in the meeting with my Doctor and me to provide technical support. I understand that I may be asked to interact with the technical support person on camera in order to fix the problem. I understand that if I decline this request and my equipment is rendered unusable for video conferencing, I may forfeit my option to use telepsychiatry and telemedicine.

• I understand that I, not Dr. Semon, am responsible for the configuration of equipment on my computer which is used for telepsychiatry and telemedicine. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. I understand that I may need to contact a designated third party (Secure Telehealth) for technical support to determine my computer’s readiness for telemedicine prior to beginning telemedicine sessions with my Doctor.

• I understand that I must be a resident of the states of Wisconsin or California to be eligible for telemedicine services from Dr. Semon.