Allergy & Asthma Center, P.C.
330 S. Garden Way #150 330-C NW Elks Dr. Candice M. Rohr, M.D.
Eugene, OR 97401 Corvallis, OR 97330 Alice H. Chou, M.D.
541-485-0316 541-754-7170 Alalia W. Berry, M.D.
Fax 541-431-0317 Fax 541-758-0707
Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical
and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education.
Health information is exchanged interactively from one site to another through electronic communications.
Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals,
and remote patient monitoring are all considered telehealth services.
_____ I understand that telehealth involves the communication of my medical/mental health information in an
electronic or technology-assisted format.
_____ I understand that I may opt out of the telehealth visit at any time. This will not change my ability to
receive future care at this office.
_____ I understand that telehealth services can only be provided to patients, including myself, who are residing
in the state of at the time of this service.
_____ I understand that telehealth billing information is collected in the same manner as a regular office visit.
My financial responsibility will be determined individually and governed by my insurance carrier(s),
Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.
_____ I understand that all electronic medical communications carry some level of risk. While the likelihood of
risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless
real and important to understand. These risks include but are not limited to:
• It is easier for electronic communication to be forwarded, intercepted, or even changed without my
knowledge and despite taking reasonable measures.
• Electronic systems that are accessed by employers, friends, or others are not secure and should be
avoided. It is important for me to use a secure network.
• Despite reasonable efforts on the part of my healthcare provider, the transmission of medical
information could be disrupted or distorted by technical failures.
_____ I agree that information exchanged during my telehealth visit will be maintained by the doctors, other
healthcare providers, and healthcare facilities involved in my care.
_____ I understand that medical information, including medical records, are governed by federal and state laws
that apply to telehealth. This includes my right to access my own medical records (and copies of medical
_____ I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant
platform, but I willingly and knowingly wish to proceed.
_____ I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic
communications by others.
_____ The healthcare provider is not responsible for breaches of confidentiality caused by an independent third
party or by me.
_____ I agree that I have verified to my healthcare provider my identity and current location in connection with
the telehealth services. I acknowledge that failure to comply with these procedures may terminate the
telehealth visit.
_____ I understand that I have a responsibility to verify the identity and credentials of the healthcare provider
rendering my care via telehealth and to confirm that he or she is my healthcare provider.
_____ I understand that electronic communication cannot be used for emergencies or time sensitive matters.
_____ I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability
to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my
healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a
biopsy, or an in-office visit.
_____ I understand that electronic communication may be used to communicate highly sensitive medical
information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or
addiction treatment (alcohol, drug dependence, etc.).
_____ I understand that my healthcare provider may choose to forward my information to an authorized third
party. Therefore, I have informed the healthcare provider of any information I do not wish to be
transmitted through electronic communications.
_____ By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission
of health information and images during a telehealth visit.
_____ I understand that there is never a warranty or guarantee as to a particular result or outcome related to a
condition or diagnosis when medical care is provided.
_____ To the extent permitted by law, I agree to waive and release my healthcare provider and his or her
institution or practice from any claims I may have about the telehealth visit.
_____ I understand that electronic communication should never be used for emergency communications or
urgent requests. Emergency communications should be made to the provider’s office or to the existing
emergency 911 services in my community.
I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature
with the opportunity to have questions answered to my satisfaction.
For electronic communication between ___________________ and staff and ___________________________.
(Healthcare provider’s name) (Patient’s name)
_____________________________________ _____________________________________
Patient or Legal Representative Signature/Date/Time Relationship to Patient
_____________________________________ _____________________________________
Print Patient or Legal Representative Name Witness Signature/Date/Time
I certify that I have explained the nature of this agreement to the patient/patient’s legal representative. I have
answered all questions fully, and I believe that the patient/legal representative (circle one) fully understands
what I have explained.
Healthcare Provider Signature/Date/Time
_______PATIENT: KEEP YOUR OWN COPY _______original placed in chart
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