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North Georgia Urology Center
1434 Broadrick Dr,
Dalton, Georgia 30720
Tel : (706) 278-5961
Email : ctallent@northgeorgiaurologycenter.com

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Telemedicine Consent Form

  • Georgia Telemedicine Informed Consent


    Telemedicine services involve the use of interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.


    ⦁ I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
    ⦁ I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
    ⦁ I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
    ⦁ If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
    ⦁ I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
    I may revoke my refusal at any time by contacting North Georgia Urology Center @ (706) 278-5961
    ⦁ I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
    ⦁ I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
    ⦁ I understand that my insurance carrier will have access to my medical records for quality review/audit.
    ⦁ I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.
    ⦁ I understand that health plan payment policies for telemedicine visits may be different from policies for in- person visits.
    ⦁ I understand that this document will become a part of my medical record.

    By clicking the below connect button, you attest to personally reading the above agreement (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand.
  • This field is for validation purposes and should be left unchanged.

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