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This consent form is what you will see in the KareoTelehealth waiting room...

HERE IS THE CONSENT FORM to participate in telemedicine. If you consent to participate in a telemedicine appointment - You simply stay in the waiting room for our appointment. If you do NOT consent, then we will cancel your visit.


1. I understand that Blue Hill Health wishes me to engage in a telemedicine consultation using kareo telehealth and I understand that video conferencing will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.


3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties, but that Tebra/Kareo Telehealth uses state-of-the-art technology and privacy controls.  I understand that Dr. Heaton or I can discontinue the telemedicine consult/visit if either or us feel that the Tebra videoconferencing connections are not adequate for the situation.


4. I understand that no other staff or providers will be present and that this interview will be conducted in a private secure area by Dr. Heaton and myself. I understand that all personal health information will be Hipaa Compliant (HIPAA is the law that governs medical privacy).


5. I understand that I have alternatives to a telemedicine consultation and the alternatives are telephone visit, or office visit or.


6. In an emergency, I understand that the responsibility of Dr. Heaton is to quickly evaluate and direct me to emergency care. Dr. Heaton cannot provide emergency care in a telemedicine visit.


7. I understand that I can ask Dr. Heaton any questions that I have about this telemed visit before I start the visit, and the time will not be included in my charges.


8. I agree to be truthful in my communication with Dr. Heaton, but that if there is an issue I do not wish to discuss I will inform Dr. Heaton.


By entering into the visit, I certify: That I have read or had this form read and/or had this form explained to me, and that I fully understand its contents.

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