To better serve the needs of people in the community, health care services provided by Daniel Campos, DNP, APRN are now available by interactive video communications and/or by the electronic transmission of information. This may assist in the evaluation, diagnosis, management and treatment of a number of health care problems. This process is referred to as “telemedicine” or “telehealth.” This means that you may be evaluated and treated by a health care provider or specialist from a distant location.
Since this may be different than the type of consultation with which you are familiar, it is important that you understand and agree to the following statements.
1. The consulting health care provider or specialist will be at a different location from me.
2. I may transmit or share electronically details of my medical history, examinations, tests, photographs or other images with the specialist who is at a different location.
3. I will be informed if any additional personnel are to be present other than myself, individuals accompanying me, and, via video, the consultant. I will give my verbal permission prior to the entry of any additional personnel.
4. Daniel Campos, DNP, APRN will keep a record of the consultation in my medical record.
5. RELEASE OF INFORMATION: Daniel Campos, DNP, APRN and/or physicians who provide professional services to the patient are authorized to furnish medical information from my emergency medical record to the referring physician, if any. Daniel Campos, DNP, APRN is authorized to release information from my medical record to any other health care facility or provider to which my care may be transferred.
6. I voluntarily consent to health care services provided by Daniel Campos, DNP, APRN, which may include diagnostic tests, drugs, examinations, and medical treatments considered necessary to treat my health problem.
7. I understand that it is my responsibility to make arrangements for follow-up care.
8. I understand that I have the option to refuse telehealth service at any time without affecting the right to future care or treatment.
In consideration for the telehealth services rendered to me, I agree to pay a non-refundable $50.00 consultation fee prior to my telehealth appointment is scheduled. Should my account be referred for collection, I agree to pay Daniel Campos, DNP, APRN reasonable attorney fees and collection expenses.