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Updated Consent for Telehealth

Below is an updated consent for telehealth; you can obtain the official form from my assistant Eric Scott Kincaid. I added in the following (listed as #5): I understand that under no conditions will Dr. Wilson ever photograph, screen shot, record video or audio, or allow any other person to view or listen to any aspect of telehealth sessions in any way.

MARK W. WILSON, MD, PC

330 WEST 58th STREET, SUITE 313

NEW YORK, NEW YORK 10019

March 24, 2020

CONSENT FOR TELEHEALTH (VIDEO) CONSULTATION

  1. I understand that Dr. Wilson is able to engage in telehealth consultation(s)/session(s).

  2. Dr. Wilson explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/healthcare provider visit due to the fact that I will not be in the same room as my provider.

  3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand Dr. Wilson or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  5. I understand that under no conditions will Dr. Wilson ever photograph, screen shot, record video or audio, or allow any other person to view or listen to any aspect of telehealth sessions in any way.

  6. I have been made aware I can have a direct conversation with Dr. Wilson, during which I have the opportunity to ask questions in regard to this procedure.

  7. I have been made aware that if I would rather meet in person, I can discuss this with Dr. Wilson.

By signing this form, I certify:

  • That I have read or had this form read and/or had this form explained to me.

  • That I fully understand its contents including the risks and benefits of the procedure(s).

SIGNATURE OF CLIENT (if 18 yo or older): X___________________________

Name of CLIENT (if 18 yo or older): ___________________________

SIGNATURE OF CAREGIVER (if under 18 yo): X___________________________

Name of CAREGIVER (if under 18 yo): ___________________________

Date: / /20

 

mark@markwwilsonmdpc.com

assistant@markwwilsonmdpc.com

(917) 441-2344

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