JC Goodwin DMD, DACSDD, DABDSM

10134 N Oracle Rd #170 Oro Valley, AZ

520-848-3889

Consent for Teleconference Service

Name:
DOB:
E‐mail:
Phone:

In the interest of improving my access to health care I understand that, for some of my appointments with Dr. Goodwin and/or his office staff, I may be offered, or request to have some of my appointments delivered using various forms of electronic communication, or telehealth conferencing.

The use of telehealth conferencing may minimize the number of actual in-office visits necessary to facilitate my ability to use the dental device to successfully manage my obstructive sleep apnea.

Alternatively, telehealth conferencing may occur between two or more offices so that I may have better access to different health care providers and/or office administrative staff without having to delay treatment or reschedule appointments.

Typical telehealth conference contacts involve the use. of computers with cameras, or, phones with cameras, and may constitute an actual face-to-face visit for the purposes of medical records. Private information such as SS#, birthdate, etc. is not included. These contacts will be documented in the doctor's medical records and become part of my legal medical record.

My participation in this system is completely elective and voluntary on my part and I may request to have regular, in-office visits instead at any time, or Dr. Goodwin's office may request that an in-office visit may be more appropriate in some circumstances.

It has been explained that teleconferencing may have some risk associated including technical difficulties and even unauthorized access, though every effort will be made to minimize this.

If my appointment for a telehealth conference session would have incurred an office visit charge if conducted in the actual practitioner's office, I may be billed for this session as well at normal rates.

By signing this form, I certify that:

I have read and understand its contents Including the risks and benefits of the procedure(s).

I have been given ample opportunity to ask questions and that my questions have been answered to my satisfaction.

I consent to the use of telehealth conferencing technology as needed to facilitate the delivery of my health care with Dr. Goodwin's office(s).

Telehealth conferencing sessions may be conducted in any of several formats,. Upon review, I prefer that my sessions be conducted using the technology selected from the following list:

Apple brand electronic devices such as IPad or iPhone, called 'FaceTime'. This is a preferred method and has been acknowledged to be a HIPPA compliant communications platform. This requires that I have access to an iPad or iPhone device.

PC electronic devices using any other computer or smart phone technology, other than Apple brand products, called 'Skype'. This is reasonably safe and secure, but, may not meet the definition of a HIPPA compliant communications platform. Use any smart phone or computer with a camera, which have been Skype enabled. I am willing to accept this risk.

Private telehealth conferencing service (ex. eVisit). This is fully HIPPA compliant service usually requiring a subscription or fee. Appropriate for the exchange of radiographs, electronic imaging, EKG, etc, or any large files of Information; it may or may not be available in all circumstances. Use any computer or phone.

Phone call only without the benefit visual or video information. This may be appropriate In some situations, but, has obvious limitations.

I decline the option of using teleconferencing technology and prefer that all contacts be in person and In-office.

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Witness signature

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