I hereby consent to the participation in the telemedicine (videoconferencing, text messaging) service of Afro Health Connect .  I understand that, because I will not be in the same room as the healthcare provider performing the service, this service is not the same as a direct patient/healthcare provider visit.

I understand that parts of my care and treatment which require physical tests or examinations will have to be conducted by providers and their staff at my location or at a third party location under the direction of the telemedicine healthcare provider.  Afro Health Connect has fully explained the nature and purpose of the videoconferencing technology and has  elaborated on the possible risks, benefits, complications (from known and unknown causes) and attendant discomforts that may arise during the telemedicine session.

Furthermore possible alternatives to the proposed sessions, including visits with a physician in-person were explained to me. I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily.  I understand that there are potential downsides to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation. 

I agree to permit my personal information such as name, age, address to be shared with other individuals for scheduling and billing. I agree to permit individuals other than my healthcare provider and the remote healthcare provider to be present during my telemedicine service to operate the video equipment, if necessary. I further understand that I will be informed of their presence during the telemedicine services. I acknowledge that if safety concerns mandate additional persons to be present, then my permission will not be needed. 

I acknowledge that I have the right to request the following: a. Omission of specific or all details of my medical history/physical examination that are personally sensitive; b. Asking non-medical personnel to leave the telemedicine room at any time if not mandated for safety concerns,  c. Termination of the service at any time. When the telemedicine service is being used during an emergency it is the responsibility of the telemedicine provider to advise my local healthcare provider regarding necessary care and treatment.  I understand that my insurance will be billed by both the local healthcare provider and the telemedicine healthcare provider for telemedicine services. I understand that if my insurance does not cover telemedicine services I will be billed directly by both the local healthcare provider and the telemedicine healthcare provider for the provision of telemedicine services. 

My consent to participate in this telemedicine service shall remain in effect for the duration of the specific service, or until I revoke my consent in writing. I accept that this agreement will be terminated if I do not attend two consecutive telemedicine appointments, without having informed the scheduling staff at Afro Health Connect prior to said appointments.  I confirm that I have read and fully understand all the above. All blank spaces have been completed prior to my submission of this form.