CONSENT TO TELEHEATH VISITS

Practice Name: Harriet Comite MD PC / Advanced Skin Care, Laser & Body Contouring Center
Practice Location: 1260 Broadcasting Road, Wyomissing, PA 19610

1. Purpose.
The purpose of this form is to get your consent for a telehealth visit with Dr. Harriet Comite and
Staff at Advanced Skin Care, Laser & Body Contouring Center. The purpose of this visit is to help
in the care of your skin problem.
2. How Telehealth Works
In a telehealth visit, you will interact in real time with your dermatologist via a secure, online
videoconferencing technology. Alternatively, the dermatologist may give you the option of
submitting a photo and chief complaint via secured electronic messaging. Your dermatologist
has the right to discontinue or not provide a consult via videoconference with secure electronic
messaging should the videoconference connection or the forwarded image be of poor quality.
You may be required to make an in-person appointment for further evaluation should this
occur. The dermatologist will look at the patient’s skin during a videoconference or review the
photos you submitted. The dermatologist will then give you advice about your dermatologic
condition and how to treat and take care of your condition. The information from the
dermatologist will not be the same as a face-to-face visit because the dermatologist is not in the
same room.
3. Pros, Cons, and Your Options.
With telehealth, a dermatologist will advise you based on viewing your condition during a
videoconference or based on the photos that were submitted electronically. Sometimes a face-
to-face follow-up visit with the dermatologist may still be needed. If you do not come into the
office for an in-person visit, the dermatologist’s advice will be solely based on the viewing your
skin condition during a videoconference or on the information and images provided by you
electronically. In the absence of an in-person physical evaluation, the dermatologist may not be
aware of certain facts that may limit her assessment or diagnosis of your condition and
recommended treatment. It is possible that there will be errors or deficiencies in the
transmission of the images of your skin condition during the videoconference or in the photos
submitted electronically that may impede the dermatologist’s ability to advise you about your
condition. Also, very rarely, security measures can fail to protect your personal information, but
the company that is providing the technology for your telehealth visit has extensive security
measures in place to prevent such failures from happening.

4. Presence of Others During the Telehealth Visit.
People other that your doctor may be a part of the patent’s care and present during the
telehealth visit. Anyone that is part of the telehealth team is supervised by the dermatologist,
and the final recommendations about your care will come from the dermatologist. Also, non-
medical people may be involved in the set up of the telehealth visit. You may ask for persons
other than your dermatologist to leave the room if you are uncomfortable having them present
during your telehealth visit
5. Medical Information and Records
All federal and state laws covering access to your medical records (and copies of medical
records) also apply to telehealth. No one other than the health care team can view your photos
or information unless you agree to give them access.
6. Privacy
All information given at your telehealth visit will be maintained by the doctors, other health care
providers, and health care facilities involved in your care and will be protected by federal and
state laws.
7. Your Rights
You may opt out of the telehealth visit at any time. This will not change your right to future care
in our practice.
8. Waiver/Release
By signing below, you understand and agree that you solely assume the risk of any errors or
deficiencies in the electronic transmission of information during your telehealth visit or in the
electronic submission of your images to your dermatologist and further understand that no
warranty or guarantee has been made to you concerning any particular result related to your
condition or diagnosis. To the extent permitted by law, you also agree to waive and release
your dermatologist and her practice from any claims you may have about this advice or the
telehealth visit generally. Your consent and release provided in this document shall remain in
effect until withdrawn by either party. Your waiver and release shall apply indefinitely for any
telehealth visits that occur during the period this waiver and release is in effect.

My doctor or her staff has talked with me about the telehealth visit. I have had the chance to ask
questions and all of my questions have been answered. I have read this form, understand the risks
and benefits of the telehealth visit, and agree to a telehealth visit under the terms explained above.

Go to the full page to view and submit the form.