UHS Telemedicine Consent Form
I hereby consent to engaging in telemedicine appointment(s) with a health care provider at the University Health Service (UHS). I understand that telemedicine services offered through the University Health Service are only made available during extreme circumstances (e.g., quarantine, pandemic, etc.) when patients are unable to meet in person with their UHS health care provider.
I understand all visits to UHS, whether in-person or through telemedicine, are confidential. UHS will not share any information about the fact or nature of a patient’s visit to UHS without the patient’s permission. Notification of others, including friends, parents/guardians, supervisors, and University administrators and faculty, is considered the patient’s responsibility unless the condition is life-threatening and the patient is unable to assume responsibility for informing others. Parental notification and consent will be obtained for patients under age 18 as required by law.
I understand the following with respect to telemedicine services provided at UHS:
- I have the right to withhold or withdraw consent at any time.
- The laws that protect the confidentiality of my personal information also apply to telemedicine. As such, I understand that the information discussed during my appointment is generally confidential. There are specific and limited exceptions to confidentiality (i.e., my condition is life-threatening and I am unable to assume responsibility for informing others). I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to other entities shall not occur without my written consent.
- The University Health Service utilizes secure Zoom software that is HIPAA compliant and a messaging system (UHSConnect) that is HIPAA compliant.
- I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of the UHS health care providers, that: the transmission of my personal information could be disrupted or distorted by technical failures; the transmission of my personal information could be interrupted by unauthorized persons; and/or the electronic storage of my personal information could be accessed by unauthorized persons.
- I understand that telemedicine-based services and care may not be as complete as face-to-face services. I understand that if my health care provider believes I would be better served by face-to-face services, I can schedule an appointment at UHS. If I am out of the Rochester area, I will be given advice for finding a provider in my area.
If I have an urgent concern, I know I can call UHS at 585-275-2662 to speak with the UHS physician on-call. Whenever UHS offices are closed, a UHS physician is on-call and available by phone for urgent concerns that cannot wait until the offices re-open. In an emergency, I should call 911. If I am on-campus, I can call Public Safety at 585-275-3333 for assistance.
I have read and understand the information provided above. I understand my UHS health care provider will ask for my verbal consent at the beginning of my telemedicine appointment.
I understand that I can speak with my provider if I do not agree with any of the statements in this consent form or if I have other questions about UHS telemedicine services. If I want to ask questions prior to my visit, I can call UHS at 585-275-2662 for assistance.