(If specific documents required / if telemedicine consultation consent)
- I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical information, both orally and visually, to health care professionals.
- I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my Provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
- I understand that Tree Top Hospital cannot guarantee that the recipient of the medical records and healthcare information will not redisclose the information to a third party.
- I understand that I can revoke my consent at any time. However, Tree Top Hospital shall not be liable and I hold Tree Top Hospital harmless for any information or records released in accordance with this form while my consent is in effect.
- I hereby release, discharge and forever acquit Tree Top Hospital from all claims of any kind, nature or description arising from or proximately caused by the Tree Top Hospital carrying out their obligations in accordance with this consent form, whether or not those claims are in my present contemplation, including but not limited to any actual or potential claims for personal injury, lack of informed consent, pain, suffering, humiliation, anguish and embarrassment, medical expenses for treatment of injuries, lost wages, income or other economic loss, disfigurement, loss of consortium and solatium, lost chance of survival, funeral expenses, damages for survival, damage to property of any kind, real or personal, or for punitive or exemplary damages, or for any and all other claims, expenses or costs, including all liens of any kind, known or unknown, attorney’s fees and other costs of litigation.
- I have read and understand the information provided above. I have discussed it with Tree Top Hospital, and all of my questions have been answered to my satisfaction.