The Southeastern Spine Institute

I agree to participate in  telehealth evaluations with Southeastern Spine Institute provider(s). By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical care. 

I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate. I understand that if I do not choose to participate in a telehealth session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation.

I understand that as with any technology, telehealth does have its limitations. There is no guarantee, therefore, that this telehealth session will eliminate the need for me to see a specialist in person. I understand that medical records of telehealth services will be kept by the provider. I understand that a limited physical examination will take place during the videoconference and that I have the right to ask my healthcare provider to discontinue the conference at any time. 

I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth appointment if it is felt that the videoconferencing connections are not adequate for the situation. 

I give my consent to be interviewed by the health care provider.  I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. 

In an emergency, I understand that the responsibility of the provider may be to direct me to emergency medical services, such as the emergency room. The provider’s responsibility will end upon the termination of the telehealth connection.

I understand that billing for the telehealth consultation may occur from the telehealth provider. Billing is at the discretion of the provider. 

I have read this document carefully and understand the risks and benefits of the telehealth appointment and have had my questions regarding the procedure explained and I hereby consent to participate in a telehealth appointment visit under the terms described herein.

I consent to receive sms text messages/emails from inviting me to my telehealth appointment.