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Virtual Visit Informed Consent Form

Teledermatology at Dermatology Associates of Ithaca involves the use of electronic communications to enable patient care "at a distance" with the goal of improving access to patient care.

While every effort is made to maximize benefit and minimize harm, as with any medical procedure, there are risks. In the case of teledermatology, possible risks include misdiagnosis (due to the inferiority of a virtual physical exam compared to an in-person exam) and technology failure during the evaluation leading to a sub-optimal patient-physician interaction. While every effort is made to safeguard your personal information, there is the rare risk of data breach with one of our HIPAA-compliant service partners. The laws that protect privacy and the confidentiality of medical information also apply to teledermatology. As always, your insurance carrier will have access to your medical records for quality reviews and audits.

In consenting to receive Teledermatology services from Dermatology Associates of Ithaca, I understand and accept the above risks involved, and acknowledge that:

• I retain the option to refuse the delivery of health care services via teledermatology at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled
• All applicable confidentiality protections shall apply to the services
• I will have access to all medical information resulting from the teledermatology services as provided by applicable law for client access to his or her medical records

As long as this consent is in force (has not been revoked), all dermatology providers at Dermatology Associates of Ithaca may provide healthcare services to me via teledermatology without the need for another consent form.

We look forward to seeing you at your Virtual Visit soon!