TELECOMMUNICATION CONSENT

CenExel RMCR
701 E. Hampden Ave Ste 510 Englewood CO 80113
Phone (303) 357-5455 | Fax (303) 357-5459

Informed Consent for Telecommunication Services

  1. Purpose. The purpose of this form is to obtain your consent to participate in telecommunication services for the purpose of conducting clinical research. Telecommunication in clinical research could involve, but is not limited to, the transfer and discussion of medical data using interactive audio, interactive video, or interactive data communication instead of in-person contact.
  2. Nature of Telecommunication Visit: Telecommunication visits will allow you to communicate with the researcher(s) at a distance. During a telecommunication session: (a) Details of you and your medical history, examinations, and tests will be discussed with you through the use of interactive video, audio, and telecommunications technology. (b) Physical examination of you may take place. (c) Other members of the CenExel RMCR staff may be present to aid in the delivery of clinical research services. You will be informed of any other people who are present, seen or unseen, and you will have the right to exclude anyone from being present during the visit.
  3. Confidentiality. All confidentiality protections required by law or regulation will apply to your session(s). Reasonable and appropriate measures have been taken to protect your privacy.
  4. Medical Records and Release of Information. The information exchanged in the telecommunication visit may become part of your medical record. You will have access to all of the information in your medical record resulting from the telecommunication services that you would have for a similar in-person visit, as provided by federal and state law. All releases of your personal health information collected during the telecommunication visit are subject to the same laws and regulations as in-person visits.
  5. Risks.  There are risks associated with the use of telecommunication. You may find it difficult or uncomfortable to communicate with the researcher(s) at a distance. You may have difficulty using the technology. The equipment or technology could malfunction causing a delay in the delivery of the services. In rare instances, the security protocols could fail, causing a breach of your personal medical information. The use of video technology to deliver services is a new technology for many and may not be equivalent to direct patient to researcher contact. Following the telecommunication services, your physician may recommend an in-person office visit for further evaluation. TELECOMMUNICATION IS NOT FOR MEDICAL EMERGENCIES. If an emergency occurs during the telecommunication visit, you will need to call 911.
  6. Right to Refuse. You have the option to refuse delivery of services by telecommunication at any time.
  7. Consent to Communications by Email or Text.  Prior to your scheduled telecommunication appointment, CenExel RMCR will send you a weblink via email or text so that you can click on it to access the correct webpage. CenExel RMCR may also send you some forms or other information via email. By providing your email address and/or mobile phone number below, you are consenting to receive these messages from CenExel RMCR via email and/or mobile phone. If you do not wish to receive email or text messages from CenExel RMCR, please do not provide your email address or mobile phone below. In such case, CenExel RMCR will call you prior to your scheduled telecommunication visit to give you the correct website address and will send you any other information via alternate means of communication. Please note that email and text messages are not secure methods of communication. This means that there is a risk that your personal information may be intercepted and read by, or disclosed to, unauthorized parties.

Mobile Phone

Email*

Legally Authorized Representative may sign on behalf of patient, but documentation is required.

Patient Name*

First Name
Last Name

Date of Birth*

Date(Required)

Agreement*

Untitled(Required)

Signature*

Use your mouse or finger to draw your signature above

Date/Time

Date

If signing on behalf of the patient, please provide the following information:

Name of Legally Authorized Representative

First Name
Last Name

Relationship to Patient

We are committed to keeping your personal information safe and secure. Any information collected will not be sold or shared with third parties.

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