Virtual Urgent Care

Maryland State Law: Definition of Telemedicine

"Telemedicine" is the use of interactive technology by a physician who is not physically present to treat a patient.

"Telemedicine" is not:

A. a telephone call;

B. an e-mail message; or

C. a fax.

Your Provider's Responsibilities in Providing Telemedicine Services

Your physician must perform an evaluation before diagnosing, treating, or prescribing to you. If you have not met your physician in person, your physician must evaluate you in real-time using audio or audiovisual technology.

Your physician must: (1) Obtain and document your consent to telemedicine services (this form); (2) Create and keep medical records; and (3) Follow laws for the confidentiality and disclosure of medical records.

About Telemedicine Services

The following are the services you may receive via telemedicine:

• Follow up on recent surgery
• Follow up on recent office visit (for acute problem)
• Follow up on chronic medical condition
• Follow up on recent emergency department visit or hospitalization
• Follow up on recent abnormal laboratory results requiring intervention
• Urinary tract Infection
• Sinus infection
• Seasonal allergies
• Skin rash
• Insect bite
• Acne
• Acid reflux

The telemedicine services you receive are not supposed to replace your normal primary care physician relationship. You should get emergency help or follow-up care when medically recommended or needed. You should also continue to see your primary care physician and other health care professionals.

The Luminis Health provider must keep your information confidential. This applies even to telemedicine services. The telemedicine technology used by your provider has security features designed to protect your personal health information.

Consent Terms

• I understand my Luminis Health provider will treat me using telemedicine technology.
• I understand my provider will not be able to provide health care services to me via telemedicine when I am not in Maryland.
• I understand I may withhold or withdraw my consent to receive health care services via telemedicine without affecting my right to receive health care services in person from Luminis Health.
• I understand telemedicine visits are an alternative to in-person visits. I understand there are other methods of medical care that I may choose at any time. My Luminis Health provider has explained the alternatives to my satisfaction.
• I understand my Luminis Health provider will discuss my health history and personal information through telemedicine technology.
• I understand and accept the risks of receiving health care services through telemedicine. Risks may include, but may not be limited to:
  • In rare cases, difficulty making a correct diagnosis or treatment decision because the provider cannot touch the patient.
  • Delays in evaluation and treatment due to issues with the telemedicine technology.
  • In rare cases, failure of software security to protect personal medical information.
  • In rare cases, adverse drug interactions, allergic reactions, or judgment errors due to lack of access to complete medical records.
• I understand there are laws that protect the privacy and confidentiality of my medical information. I understand these laws apply to telemedicine. I understand my protected health information will not be disclosed without my consent, except as permitted by law. I understand I have the right to obtain copies of my health records, including my telemedicine records.
• I agree not to record, stream, or capture my telemedicine communications with my Luminis Health provider.
• I understand results cannot be guaranteed for telemedicine services.
• I understand if my health insurance does not fully cover the cost of telemedicine services, I may be responsible for the payment.
• I understand my Luminis Health provider may determine telemedicine services are not right for me and may choose not to provide telemedicine services to me.
• I understand agreement below means I agree to receive health care services via telemedicine under the terms of this form.

Patient Consent to the Use of Telemedicine

I read and understood the information provided above. I talked about this form with my provider or other health care staff. All of my questions were answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.