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Telehealth Consent

Your rights and limitations regarding telehealth are found below. Please provide your consent in your Patient Portal.

My rights concerning telehealth appointments 

I understand:

  • I have the right to withhold or withdraw consent at any time. This will not affect my right to future care or treatment, or risk the loss or withdrawal of any benefits to which I would otherwise be entitled. The laws that protect the confidentiality of my medical information also apply to telehealth.
  • That the same laws that give me the right to access my medical information and copies of medical records in accordance with California law also apply to telehealth. I must inform my provider of the exact location in which I will consistently be during the telehealth appointment and inform them if this location changes.
  • That the dissemination of any personally identifiable images or information from the telehealth interaction to researchers or other entities shall not occur without my written consent.
  • That I can only engage in appointments when I am physically in California. The provider will confirm this each session.
  • That I will only engage in appointments from a private location where I will not be overheard or interrupted.
  • That I am not to record any appointments, nor will the SHS record my session without my written consent.

Potential Risks, Consequences and Limitations of Telehealth 

I understand:

  • That telehealth appointments should not be viewed as a substitute for face-to-face visits with a medical provider. It is an alternative form of receiving medical care with certain limitations. Telehealth is relatively new and, therefore, lacks research indicating that it is an effective means of receiving care.
  • That telehealth is not appropriate if I am having an emergency, an urgent problem or a crisis.
  • That telehealth may lack visual and/or audio cues, which may increase the likelihood of being misunderstood.
  • That telehealth may have disruptions or delays in service and/or quality, depending on the technology used.
  • That, in rare cases, security protocols could fail and my confidential information could be accessed by unauthorized persons.

 

If you feel your rights have not been respected, or wish to file a complaint, compliment or suggestion, you can:  

  1. Fill out our Patient Satisfaction Survey by clicking here.
  2. Complete a "how are we doing" form in the reception room and drop in locked box.
  3. Contact the SHS Quality Improvement Chair at 661-654-3453 or at edelamar@csub.edu.
  4. Ask to speak to the Quality Improvement Chair or SHS Director in person.