Texas Liver Institute Telemedicine Policies and Informed Consent

TLI is offering telemedicine services to our patients. This document provides our policy regarding patient confidentiality and consent for these services.

Telemedicine involves the use of electronic communications to enable health care providers to provide non face- to-face patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

  • Patient medical records
  • Medical images
  • Live two-way audio and/or video

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

  • Improved access to medical care without the need for travel.
  • Obtaining expertise of your specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medicalinformation;
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions orallergic reactions or other judgment errors

By submitting this form, I understand the following:

  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
  3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
  4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.
  5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas.
  6. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
  7. I understand that my insurance will be billed for the telemedicine visit as allowed by Texas law. I may or may not have a copay associated with this service.

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I hereby authorize Texas Liver Institute to use telemedicine in the course of my diagnosis and treatment.

Telemedicine Printable Form

Click the button below to download the consent form and send it in to Texas Liver Institute.

Download Consent Form Submit Telemedicine Consent Form