Consent to Treatment 

Telemedicine Definition 

Telemedicine is the remote delivery of healthcare services, such as clinical and diagnostic assessments, over a telecommunication infrastructure such as phones, tablets, and computers. Providers may include physicians, nurse practitioners, or physician assistants. Any of the following may be used for diagnosis, therapy, follow-up and/or education: 

  • Patient medical records

  • Diagnostic tests

  • Medical images

  • Live two-way audio and video

  • Output data from medical devices and sound and video files

Services rendered by Physician 360 ™ do not replace the relationship you have with your primary care physician or specialist providers. Day to day responsibility for your patient care should remain with the your local clinician.

Benefits of Using Physician 360 ™ 

  •  Improved access to medical care by enabling a patient to be treated by a healthcare practitioner at distant site

  •  Decreased delay to diagnosis and treatment

  •  Decreased cost for medical evaluation and management

Potential 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:

  • Your symptoms might be too severe or concerning to be treated by a telemedicine visit and you will be referred to an urgent care center or emergency room.

  • The consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient.

  • 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 the privacy of personal medical information (see Section Video Encounter Privacy below).

  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.



By checking the box associated with “Informed Consent”, You acknowledge that you understand and agree with the following:

Consent to Medical Care: The undersigned consents to care provided during this interaction, which may include but is not limited to laboratory procedures, medical treatment and services rendered to the patient under the general and special instructions of the patient’s medical provider.


Release of Information: I agree that Physician 360 may disclose my ‘protected health information’ (PHI) in compliance with HIPAA Privacy Provisions which may include my medical records to any third-party payers, including but not limited to health insurers, health care service plans, state and federal agencies, workers compensation carriers, manufacturers required by FDA to track medical devices, or my employer. This includes appropriate release of, and disclosure of, my medical records in compliance with the Privacy Provisions to my physicians and other health care providers when necessary for my treatment and general health. Physician 360 has permission to disclose pertinent information to family members, friends or designated caregivers who may be present with me during the video encounter or laboratory test procedures. I understand that if I am not present in the video viewfinder, my personal health information will not be disclosed or discussed unless I agree to disclose.


Video Encounter Privacy: Physician 360's interactive platform is HIPAA compliant. The 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.

However, in the event that our platform is experiencing a technical error, or is incompatible with your personal computer system, it may become necessary to transition to an alternative platform that is not properly encrypted or HIPAA compliant. While we do not store any of the information transmitted during that encounter, making a breach of confidentiality unlikely, we cannot guarantee that individuals outside of our company will not be able to gain access to a patient's medical information. In the setting of technical difficulties which would preclude the use of our HIPAA compliant platform, the medical provider will give you the option to use a non-HIPAA compliant platform. Of course, it is always your right to discontinue the encounter and seek medical care elsewhere.


Personal Valuables: Physician 360 shall not be liable for the loss or damage to any money, jewelry, documents, furs, fur coats, electronics, garments, other articles of unusual value and small size or any personal property by the medical products being used in the home setting. Patient agrees to keep medical products out of the reach of children or pets. 


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 written consent.

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.

I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation.

I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

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.

I have read and understand the information provided above regarding telemedicine.

I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.