To whom may we discuss their health information:

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Chest pain, palpitations, shortness of breath when lying flat.

Nausea, vomiting, acid reflux, blood in stool, abdominal pain, diarrhea, constipation.

Swollen lymph nodes, easy bruising, easy bleeding.

Increased thirst, heat or cold intolerance.

Joint pains, joint swelling, muscle weakness.

Painful or frequent urination, blood in urine, urinary or fecal incontinence, urinary urgency.

Normal or abnormal.

I request and authorize Dr. J. Preston Parry, 149 Fountains Blvd, Madison, MS 39110, to release healthcare information of the patient named above to:

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Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papillomavirus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

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THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.

Select all that apply:*

Messages

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Witness

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Telemedicine lets a doctor care for you, even when you cannot see him or her in person. The doctor uses the Internet or other technology to:

• give you advice,
• give you an exam, or
• do a procedure through online communications.

Telemedicine can also be used to:

• get prescription refills,
• book an appointment, or
• let your doctor talk with other providers about your health problem or treatment.

Telemedicine is more than a phone call, an email, a fax, or an online questionnaire. Sometimes you may need to come to a healthcare facility to use their equipment (TV screen, camera, or Internet). A provider may use technology tools or medical devices to check on your health remotely. If you agree, part of your health record may be sent to the telemedicine provider before your session. You and your healthcare team must decide if your health problem can be helped with telemedicine. The team and others involved in your care (e.g., medical home or hospital teams) will make a plan for your care using telemedicine. This will also include a plan in case you have an emergency during the telemedicine session. If the patient is a minor child, the telemedicine provider will explain to the parent how a telemedicine exam is different from an in-person exam. He or she will also explain if a complete exam of the child is possible.

Your Telemedicine Session

During your telemedicine session:

• The provider and the staff will introduce themselves.

• When starting a session, you may be asked to confirm the state you are in and the state where you live.

• The provider may talk to you about your health history, exams, x-rays, and other tests. Other providers may take part in this discussion.

• A visual and/or partial physical exam may take place. This may happen by video, audio, and/or with other technology tools. A nurse or other healthcare staff may be in the room with you to help with the exam.

• Non-medical staff may be in the room to help with the technology.

• Video and/or photo records may be taken, and audio recordings may be made.

• A report of the session will be placed in your medical record. You can get a copy from your provider.

All laws about the privacy of your health information and medical records apply to telemedicine. These laws also apply to the video, photo, and audio files that are made and stored.

Risks and Common Problems

Many patients like telemedicine because they do not have to spend time and money on travel to see a certain healthcare provider in person. Also, they can see a provider who they might not be able to see otherwise. Technology can make getting health care easy, but there can also be problems:

• If there is an equipment or Internet problem, your diagnosis or treatment could be delayed.

• Records or images that are taken and sent may be poor quality. This can delay or cause problems with your diagnosis or treatment.

• The records sent for review before the session may not be complete. If this happens, then it may be hard for the telemedicine provider to use his or her best judgment about your health problem. For instance, you could react to a drug or have an allergic response if the provider does not have all of the facts about your health.

• There could be problems with Internet security and privacy. For instance, hackers may access or view your health information. If this happens, then your medical records may not stay private.

• If there is a technology problem, the information from your session may be lost. This would be outside the control of your doctor and the telemedicine provider.

• Without a hands-on exam, it may be hard to diagnose your problem.

More Facts

A main goal of telemedicine is to make sure that you get good, personal health care, even though you are not seeing a provider in person.

Some states may require you to have a face to face visit first and a yearly visit with your doctor before telemedicine treatment can happen. Telemedicine providers must follow the same rules for prescribing drugs just as they would for an office visit. Before your session, you will learn about which drugs telemedicine providers can and cannot prescribe. Having a telemedicine session is your choice. Even if you have agreed to the session, you can stop your medical records from being sent - if this has not happened yet. You can stop the session at any time. You can limit the physical exam. You will be told about all the staff who will take part in the session. You can ask that any of these people leave the room to stop them from seeing or hearing the session. It is up to you to make sure the setting for your session is private. It should only include people who you are willing to share health information with. Your telemedicine provider can ask that people with you leave the room to make sure your session is private. Your session may end before all problems are known or treated. It is up to you to get more care if your health problem does not go away. You will be told how long it might take to respond to your emails, phone calls, or other types of messages.

Before your session, you may want to ask how much of the cost will be covered by your insurance and how much you may owe.

Patient Acknowledgment

This form gives you facts about and risks of telemedicine sessions. By signing this form, you agree that you have read, understand, and agree with these terms. I also confirm by my signature below that:

• I have been told the name and credentials of my telemedicine provider,

• I have been able to ask questions about telemedicine sessions,

• All of my questions have been answered,

• I understand no guarantees have been made about success or outcome, and

• I agree to take part in a telemedicine session.

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What is Preventative Care? 

According to the Women’s Preventative Services Initiative,¹ “a preventative care visit is defined as a clinical encounter that addresses issues of general wellness and provides screening, immunizations, counseling, and other prevention services for a variety of health conditions. Visits facilitate access to health care services, identify risk factors, and reduce likelihood or delay the onset of disease.”   

Specifically, the American College of Obstetricians and Gynecologists² (ACOG) recommends annual health assessments and routine annual exams for women ages 13 and above as an opportunity to counsel patients about preventative care and to provide or refer for recommended health services. These assessments should include screening, laboratory and other tests, counseling, and immunizations based on age and risk factors. The interval for individual services varies.

Preventative health care visits for women can be performed by a qualified primary care provider, family medicine provider, or general OBGYN.

What Type of Care Am I Receiving at Positive Steps Fertility^®? 

Your team of providers at Positive Steps Fertility^® (PSF) are fertility specialists that are providing specialized care that focuses on fertility and infertility related disease processes. Your treatment team is not providing preventative health care services as defined by the Women’s Preventative Services Initiative. By not focusing on your preventative health care services, your team of providers at Positive Steps Fertility are able to fully dedicate their time and attention to your fertility specific needs that brought you to our clinic.

Positive Steps Fertility fully supports the guidelines as outlined by the Women’s Preventative Services Initiative and ACOG. Moreover, we expect that each of our patients adhere to those guidelines as it relates to their preventive health care visits with their respective primary care or gynecologic providers. It is the responsibility of the patient to inform their reproductive endocrinologist if any condition is identified that may impact their ability to undergo fertility treatments/services, or limit/impair their ability to become pregnant or carry a pregnancy safely. Additionally, it is your responsibility to notify us if there are others changes that may shift legal or workflow considerations relating to therapy, (e.g. a different relationship status such as death of a spouse, separation, divorce, etc.).

Acknowledgement 

I have read this acknowledgement and understand all of the information and have had the opportunity to ask questions. I understand and agree to these discussed preconditions for receiving care at PSF, including specifically that it is my responsibility to maintain my preventative care visits with either my primary care physician or general OB/GYN, as well as to address and treat broader non-fertility aspects of my health with clinicians outside of PSF should these apply. It is my responsibility to inform the PSF team about any change in my health or condition that may negatively impact my fertility treatment or my ability to become pregnant or carry a pregnancy in the future.  

References 

1. Women’s Preventative Services Initiative. Available online at: https://www.womenspreventivehealth.org/recommendations/well-woman-preventive-visits/
2. The American College of Obstetricians and Gynecologists.  Available online at:  www.acog.org

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