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Consent and Privacy information

Covid-19 State of Emergency Telehealth Consent

I, agree to receive telehealth services during the Covid-19 state of emergency in 2020.   I understand that:

  • Telehealth includes the use of interactive video and/or audio communications to provide some forms of health care.
  •  I understand there are risks associated with telehealth, including the possibility, that the transmission could be disrupted, distorted or interrupted by unauthorized persons.
  • The method of audio or visual communication I choose on my end, determines the security of the application or device I use.
  •  I understand that I may be directed to “face-to-face” care, if deemed appropriate.
  •  I understand that the laws that protect confidentiality of my in-person visits apply to telehealth visits.
  •  I understand that my healthcare information may be shared with other individuals during the consultation other than my provider in order to operate video equipment, but that I will be informed of their presence.
  •  I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future face-to-face care. 

Estado de emergencia Covid-19 Consentimiento de telesalud

Yo, acepto recibir servicios de telesalud durante el estado deemergencia de Covid-19 en 2020. Entiendo que:

  • La telesalud incluye el uso de comunicaciones interactivas de video y / o audio para proporcionar algunas formas de atención médica.
  • Entiendo que existen riesgos asociados con la telesalud, incluida la posibilidad de que la transmisión pueda ser interrumpida, distorsionada o interrumpida por personas no autorizadas.
  • El método de comunicación de audio o visual que elijo por mi parte determina la seguridad de la aplicación o dispositivo que uso.
  • Entiendo que me pueden dirigir a recibir atención ” de cara a cara”, si se considera apropiado.
  • Entiendo que las leyes que protegen la confidencialidad de mis visitas en persona se aplican a las visitas de telesalud.
  • Entiendo que mi información de atención médica puede compartirse con otras personas durante la consulta además de mi proveedor para operar equipos de video, pero que se me informará de su presencia.
  • Tengo derecho a retener o retirar mi consentimiento para el uso de telesalud en el transcurso de mi atención en cualquier momento, sin afectar mi derecho a recibir atención de cara a cara en el futuro.

 

This website is for a Health Center Program grantee under 42. U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233 (g) – (n). This organization is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant #H80CS00689 titled Health Center Cluster for $7,161,610 with about 88% funded with nongovernmental sources. This information or content and conclusions are those of Great Lakes Bay Health Centers and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. We are an equal opportunity provider and employer. GLBHC participates in the Federal program 340B Drug Pricing Program. All GLBHC patients may exercise his or her freedom to choose a pharmacy provider.

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