TELEMEDICINE AND TELEHEALTH SERVICES AGREEMENT (“Agreement”)
Telemedicine is the remote delivery of healthcare services, which can be achieved using
technology and typically occurs when the healthcare provider and patient are not in the same
physical location. User information is transmitted electronically and may be used for
diagnosis, treatment, follow-up, and/or patient education. Any and all patient records
including but not limited to Patient medical records, Medical images, Interactive audio,
Interactive video, data communications, Output data from medical devices, sound and video
files can be included.
Medical Information and Medical Records Security
MyWorkDoc employs the highest level of network and software security protocols to protect the
confidentiality of patient information and data and includes measures to safeguard patient
data and to aid in protecting against intentional or unintentional corruption of health
information are in place. All existing laws regarding privacy and security of your health
information and copies of your medical records apply to this telemedicine health service and
the audio and video information transmitted, received and stored electronically as part of
It is understood that the resulting video images and audio recordings of the patient, or any
likeness of the patient, may be captured and stored electronically with MyWorkDoc. These
recordings and complete medical information may be viewed and used for the purposes of
evaluation, training, research, and otherwise, which may include MyWorkDoc personnel and its
affiliates. By participating in a telemedicine or telehealth consultation service, it is
understood and consent is given by the patient to MyWorkDoc to use any images, audio
recordings and medical information provided by the patient for the purpose of outlined
A patient may withhold or withdraw consent to the telemedicine or telehealth service at any
time before or during consult without affecting the right to future care or treatment. The
request to revoke consent must be in writing and received by MyWorkDoc. Please see
MyWorkDoc’s Privacy Statement. If you revoke your consent, the video images and audio
recordings will be destroyed and no longer used by MyWorkDoc. Any uses of the video made
with your permission prior to MyWorkDoc’s receipt of your revocation cannot be changed or
Risks and Benefits
By agreeing to the telemedicine or telehealth consultation, it is understood that video
and/or audio technology will be used to conduct the health service, and that there are
limitations to the technology and the process of telemedicine, including the potential for
incomplete exchange or loss of information. Also, it is understood that In the course of
this medical evaluation, only information that is presented directly to the provider during
the consultation can be used and MyWorkDoc or its providers and affiliates are not
responsible for liabilities related to critical information that is omitted by the patient
or that is not gathered during the consultation.
As with any medical procedure, there may be potential risks associated with the use of
telemedicine or telehealth. These risks include, but may not be limited to:
- Information transmitted may not be sufficient (e.g., poor resolution of images) to allow
for appropriate medical decisions to be made by the provider.
- The provider may not be able to provide medical treatment to the patient using
telemedicine equipment nor provide for or arrange for any emergency care that may be
- Delays in medical evaluation and treatment could occur due to deficiencies or failures
of the equipment or software.
- Security protocols could fail, causing a breach of privacy of confidential medical
- A lack of access to complete medical records may result in errors and medical
- The patient has had the alternatives to a telemedicine consultation explained to them,
and in choosing to participate in a telemedicine consultation, it is understood that
some parts of the exam involving physical tests may not be conducted. Payment and
communication with Health Savings Accounts, Insurance, or Flexible Spending Accounts is
the responsibility of the patient or the patient representative.
- If at any time before, during, or after the telemedicine/telehealth consultation there
is a concern for a medical emergency or if the patient’s medical condition is worsening,
it is understood that immediate local emergency services will be obtained and this is at
the sole discretion and liability of the patient or patient’s guardian.
- The patient and/or guardian have the right to inspect all information obtained and
recorded during the course of the tele medicine interaction, and may receive copies of
this information for a reasonable fee. Such inspection and copying of records shall be
subject to MyWorkDoc or affiliates policies and procedures.
- The anticipated benefits, diagnosis and results of care from the use of telemedicine
cannot be guaranteed. If the medial condition of the patient is not improved, then the
patient will seek local emergency care as needed and as decided by the patient or
- It is understood that the patient’s condition may require a referral to a specialist for
further evaluation and treatment.
- It is understood that there are alternatives to using telemedicine or telehealth for
medical care needs.
- The written information provided here is understood and the patient or guardian hereby
voluntarily and freely agrees and gives consent to take part in the telemedicine health
service, and to any related evaluation, assessment, and diagnosis as the consulting
health care provider deems appropriate for their current medical condition and the
- Any and all questions can be sent directly at any time to MyWorkDoc via email at email@example.com
MyWorkDoc Consent (“Consent”)
Telemedicine involves the use of electronic communications to enable healthcare providers at
different locations to share individual patient medical information for the purpose of
improving patient care. Providers may include primary care practitioners, specialists,
and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or
education, and may include the following:
- Patient medical records
- Medical Images
- Live two-way audio and video
- Output data from medical devices and sound video files
Electronic systems used will incorporate network and software security protocols to protect
the confidentiality of patient identification and imaging data and will include measures to
safeguard the data and to ensure its integrity against intentional or unintentional
- Improved access to medical care by enabling a patient to remain in his/her remote site
while the physician obtains test results and consults from healthcare practitioners at
- More efficient medical evaluation and management.
- Obtaining expertise of a distant specialist.
As with any medical procedure, there are potential risks associated with the use of
telemedicine. These risks include, but may not be limited to:
- In rare cases, information transmitted may not be sufficient (e.g. poor resolution of
images) to allow for appropriate medical decision making by the physician and
- Delays in medical evaluation and treatment could occur due to deficiencies or failures
of the equipment;
- In very rare instances, security protocols could fail, causing a breach of privacy of
personal medical information;
- In rare cases, a lack of access to complete medical records may result in adverse drug
interactions or allergic reactions or other judgement errors;
By using the telemedicine software, I understand the following:
- I understand that the laws that protect privacy and the confidentiality of medical
information also apply to telemedicine, and that no information obtained in the use of
telemedicine which identities me will be disclosed to researchers or other entities
without my consent.
- I understand that I have the right to withhold or withdraw my consent to the use of
telemedicine in the course of my care at any time, without affecting my right to future
care or treatment.
- I understand that I have the right to inspect all information obtained and recorded in
the course of the telemedicine interaction, and may receive copies of this information
for a reasonable fee.
- I understand that a variety of alternative methods of medical care may be available to
me, and that I may choose one or more of these at any time. My provider has explained
the alternatives to my satisfaction.
- I understand that telemedicine may involve electronic communication of my personal
medical information to other medical practitioners who may be located in other areas,
including out of state.
- I understand that it is my duty to inform my provider of electronic interactions
regarding my care that I may have with other healthcare providers.
- I understand that I may expect anticipated benefits from the use of telemedicine in my
care, but that no results can be guaranteed or assured.
- I understand that I have had the opportunity to make reasonable inquiries regarding all
procedures and benefits to be utilized in connection with the terms and provisions
- I understand that to the fullest extent permitted by law I agree to release MyWorkDoc
from and against any and all claims, losses, bodily injury, illness, disease or death or
for loss of services, wages, attorneys fees or costs to the extent caused by the
negligence of the providers (it being expressly understood that MyWorkDoc is not a
“provider” as that word is used in the Agreement and Consent) except to the extent
prohibited by applicable law.
- I understand that no amendment of any of the foregoing information or anything contained
in this App shall be effective unless in writing and signed by MyWorkDoc and me.
- I understand that if any provision herein is held to be partially or completely contrary
to law and/or unenforceable, the information supplied above shall be deemed to be
amended to partially or completely modify such provision or portion thereof to the
extent necessary to make it enforceable or if necessary shall be deemed to be amended to
delete the unenforceable provision or portion thereof.
- I understand that this Agreement and Consent shall be governed by the laws of the State
of Texas, excluding any conflicts of law rules.
- I understand that I voluntarily submit to the jurisdiction and venue of the State courts
located in Longview, Gregg County, Texas for any matters arising under this Agreement
- I understand that to the maximum extent permitted by law, except for fraud or gross
negligence, I knowingly, voluntarily, and intentionally waive any right to
consequential, exemplary or punitive damages in regards to MyWorkDoc with respect to any
dispute, regardless of the forum for the proceedings.
Patient Consent to The Use of Telemedicine
I have read and understand the information provided above in the Agreement and Consent
regarding telemedicine, have discussed it with my physician or such assistants as may be
designated, and all of my questions have been answered to my satisfaction. I hereby give my
informed consent for the use of telemedicine in my medical care.