Video Telehealth Visit Notice

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1. I understand that my doctor wishes me to engage in a telemedicine consultation.
    

2. Soho Otolaryngology and its staff have explained to me how the video conferencing technology will be used. Such a consultation will not be the same as a direct patient-physician visit because I will not be in the same room as my physician.
    

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

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. If others are present at the healthcare visit to assist with setting up equipment for the use of telemedicine, I understand that I will be informed of their presence in the consultation and thus will have the right to request the following:

   • omit specific details of my medical history/physical examination that are personally sensitive to me

   • ask non-medical personnel to leave the telemedicine examination room; and/or

   • terminate the consultation at any time.
      

5. I have had the alternatives to a telemedicine consultation explained to me, and I am choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location in the direction of the consulting health care provider.
    

6. I understand that Soho Otolaryngology will bill me and/or my insurance (if this is a covered form of a visit).
    

7. I have had a direct conversation with my physician's office staff, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand.

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中文

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1. 我明白我的醫護人員希望我參網上掛號醫療諮詢。

2. 我的醫護提供者向我解釋了如何使用網上視頻技術。這種諮詢不會與直接病人/醫護人員探訪相同，因為我不會與我的醫護人員在同一房間。
    

3. 我知道這項技術存在潛在風險，包括中斷、未經授權的訪問和技術困難。我知道，如果我的醫護人員或我覺得網上掛號連接不足以應付這種情況，我們可以停止網上醫療諮詢/訪問。
    

4. 我知道，出於日程安排和計費目的，我的醫療保健資訊可能會分與其他人。其他人也可能在諮詢期間，除了我的醫生在網上掛號期間，以操作視頻設備。上述人員均會對所獲得的資料保密。我並且明白，醫生將告知我他們在期間中有在，因此我也有權要求下列事項:
    

   • 不說出對我個人敏感的病史/體格檢查的具體細節；

   • 要求非醫務人員離開檢查室；或者

   • 隨時終止會診。
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5. 我已向我解釋遠端醫療諮詢的替代方案,以及選擇參加遠端醫療諮詢。據我瞭解,涉及體格檢查的 部分內容可能由我所在地點的個人在諮詢醫護人員的方向進行。
    

6. 我知道帳單將來自我的執業者,以及我介紹的網站的設施費。
    

7. 我與醫生的證所人員進行了直接交談，在此期間，我有機會就這個程式提出問題。我的問題已經得到解答，風險、好處和任何實際選擇都用我理解的語言與我討論過。

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