Specifications

AUTHORIZATION AND CONSENT TO PARTICIPATE IN
EyePACS TELEMEDICINE CONSULTATION
The purpose of this form is to obtain your consent to participate in EyePACS, a program
providing Diabetic Retinopathy Screenings by the use of Telemedicine Consultations.
Your doctor, __________has determined that telemedicine consultation may provide you
with access to services and expertise not otherwise available.
Details of your medical history, examinations, and tests will be discussed with other
health professionals at one or more other locations through telecommunications
technology.
Other medical or nonmedical personnel may be present and may not be visible at the
consultant’s location or other sites as observers and technical assistants. Reasonable and
appropriate efforts have been taken to reduce the risks associated with telemedicine
consultation and all existing confidentiality protection under federal and California laws
apply to information disclosed during this telemedicine consultation. Despite these
measures and protection there is a possibility that: the transmission of medical
information may be disrupted or distorted by technical failures in transmission;
unauthorized persons may intercept the transmission of medical information; the
electronic storage of information generated by this telemedicine consultation in one or
more databases could be accessed by unauthorized persons.
My Rights. It is understood that the patient participating in a telemedicine consultation
may:
a. Request that the participating doctor omit specific details of the history or
examination that are personally sensitive.
b. Limit any physical examination proposed during the telemedicine consultation.
c. Request that nonmedical personnel leave the consultant’s location at any time.
d. Request that all personnel leave the consultation site in order to have a private
consultation with the off-site provider.
e. Withhold or withdraw consent to this procedure without affecting rights to future
care or treatment.
f. Access all medical information transmitted during this telemedicine consultation,
and obtain copies of this information for a reasonable fee.
I have reviewed this consent form and have had any questions regarding this telemedicine
consultation answered to my satisfaction.
I consent to the use of telemedicine for the procedure(s) described above and release
__________________from any and all liability arising from my participation subject to
the limitations pursuant to My Rights as outlined above.