Patient Forms

Dr.Jared Shippee
ihealwounds@drshippee.com
435.200.5756

Telewound informed consent form
I ___________________________________________________________________________________
hereby consent to engaging in tele-wound care with Dr. Jared Shippee DPM as part of my wound care. I understand that “tele-wound care” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in South Dakota or outside of South Dakota. I understand that I have the following rights with respect to telemedicine:
(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
(2) The laws that protect the confidentiality of my medical information also apply to tele-wound care. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the tele-wound care may be used for clinical case studies or research for publishing and presentations.
(3) I understand that there are risks and consequences from tele-wound care, including, but not limited to, the possibility, despite reasonable efforts on the part of my treatment, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, I understand that tele-wound care based services and care may not be as complete as face-to-face services. I also understand that if my wound specialists believes I would be better served by another form of wound care (e.g. face-to-face services) I will be referred to a wound specialist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of wound care, and that despite my efforts and the efforts of my wound care specialist, my condition may not improve, and in some cases may even get worse. (4) I understand that I may benefit from tele-wound care, but that results cannot be guaranteed or assured. (5) I understand that I have a right to access my medical information and copies of medical records in accordance with South Dakota law. I have read and understand the information provided above. I have discussed it with my wound care specialist, and all of my questions have been answered to my satisfaction

Signature:_________________________________________________________Date:_______________________

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