The Clinical Skin Center of Northern Virginia, PLLC

Patient Authorization and Informed Consent for Telemedicine
(for Virtual Visits within the State of Virginia)

Patient Name:*		Date of Birth:*

1. I understand that my health care provider will engage with me in a telemedicine consultation.
2. My health care provider has explained to me how the video, audio and still photographic conferencing technology will be used to affect such a consultation. I understand that this will not be the same as a direct patient/healthcare provider visit due to the fact that I will not be in the same room as my health care provider.
3. 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 telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to provide medical support and/or technical assistance. The above-mentioned people will all 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.
5. During the public health crisis, by order of Department of Health Human Services HHS, a limited waiver on HIPAA Privacy rules is in effect. This allows medical practices to facilitate easier and better communication with patients and enable widespread use of telemedicine consultation. The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. This health information may not be protected under the Health Insurance Portability and Accountability Act (HIPAA) and may not be 100 percent secure.
6. I understand the alternatives to a telemedicine consultation. In choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
7. I understand that the practice of Dermatology often involves physical tests which may only be conducted during in-person visits in our office. I agree that is my responsibility to follow-up in a timely manner for any tests or biopsies as ordered or directed by my provider. I understand that any remaining medical concerns, persistent or worsening lesions, rashes or symptoms require further prompt evaluation in-person.
8. I understand that billing will occur from my practitioner just as it would for an in-office visit and I will be responsible for any applicable copays and/or deductibles as determined by my insurance carrier.
9. I have had the opportunity to ask questions in regard to this form and this procedure. My questions have been answered to my satisfaction and I understand the risks, benefits and any practical alternatives to a Telemedicine Consultation.
10. Telemedicine services are only offered and available for patients who are physically located in VA at the time of the virtual visit. By signing below, I agree that I will only participate in a telemedicine visit within the state of Virginia.        (Rev. 2-15-2022)

Patient’s/Guardian Signature:		Date: