Informed Consent for Telehealth Services

1. Nature and Scope of Telehealth

Telehealth involves the use of electronic communication technologies to deliver healthcare services when the patient and the healthcare provider are not in the same physical location. During your telehealth consultation with Bertrand Desilva MD INC., you will interact with your provider through a secure, real-time video and audio platform.

In the context of sleep medicine, telehealth may be used for:

• Initial sleep medicine consultations and evaluation of sleep complaints
• Review and interpretation of home sleep test results and in-lab sleep study findings
• Diagnosis of sleep disorders, including obstructive sleep apnea and other sleep-related conditions
• Treatment planning, including CPAP therapy initiation, oral appliance therapy coordination, and behavioral recommendations
• Follow-up appointments to monitor treatment progress, adjust therapy settings, and address ongoing concerns
• Prescription of medications and durable medical equipment related to sleep disorders

2. Your Rights

As a patient receiving telehealth services, you have the following rights under California law:

• Right to Withdraw Consent: You have the right to withdraw your consent for telehealth services at any time, before or during your consultation, without affecting your right to future care or treatment. You may also choose to discontinue telehealth visits at any point.
• Right to Request In-Person Visit: You have the right to request an in-person visit with a healthcare provider at any time. If telehealth is not appropriate for your condition, your provider will recommend in-person evaluation and provide appropriate referrals.
• Right to Information: You have the right to receive information about the provider conducting your telehealth visit, including their qualifications, credentials, and licensing.
• Right to Privacy: You have the right to the same level of privacy and confidentiality during a telehealth visit as you would during an in-person visit.

3. Benefits of Telehealth

Telehealth consultations offer several potential benefits:

• Convenience: Attend your appointment from the comfort and privacy of your own home or another private location, without the need to travel to a clinic.
• Improved Access: Access board-certified sleep medicine expertise regardless of your distance from our office, particularly beneficial for patients in underserved or rural areas of California.
• Reduced Travel: Eliminate travel time, transportation costs, and the need to take extended time away from work or family responsibilities.
• Timely Follow-Up: Facilitate more frequent and timely follow-up visits to monitor treatment progress and make adjustments.
• Continuity of Care: Maintain consistent access to your sleep medicine provider without interruption.

4. Risks and Limitations

Telehealth, like all forms of healthcare delivery, has certain risks and limitations that you should understand:

• Technology Failures: The quality of your telehealth visit may be affected by technical factors, including poor internet connectivity, hardware malfunctions, or software errors. These issues may result in interruptions, delays, or degraded audio and video quality. In rare cases, a visit may need to be rescheduled due to technical difficulties.
• Inability to Perform Physical Examination: Telehealth does not allow the provider to perform a hands-on physical examination. Certain clinical findings that would be apparent during an in-person visit may not be detectable via video.
• Potential Need for In-Person Follow-Up: Based on the information gathered during your telehealth visit, your provider may determine that an in-person examination, additional diagnostic testing, or referral to another specialist is necessary to complete your evaluation or treatment.
• Security Risks: Despite the use of encryption and secure platforms, electronic communications carry an inherent risk of interception or unauthorized access.
• Diagnostic Limitations: In some cases, the provider may not be able to make a definitive diagnosis solely through a telehealth visit and may need to order additional testing.

5. Privacy and Security

We take the privacy and security of your health information seriously:

• HIPAA-Compliant Platform: All telehealth visits are conducted using a platform that complies with the Health Insurance Portability and Accountability Act (HIPAA). The platform vendor has executed a Business Associate Agreement (BAA) with our practice.
• Encryption: Audio and video transmissions during your visit are encrypted using industry-standard protocols to protect against unauthorized interception.
• Limitations of Electronic Communication: While we implement robust security measures, no electronic communication system is entirely immune from risk. Unauthorized third parties may potentially intercept electronic communications despite encryption and security protocols.
• Your Responsibility: You are responsible for ensuring that your telehealth visit takes place in a private setting and that your device and internet connection are secure. Avoid using public Wi-Fi networks during your visit.

For full details on how we handle your health information, please review our Privacy Policy.

6. Technology Requirements

To participate in a telehealth consultation, you will need:

• Device: A computer, tablet, or smartphone with a functioning screen capable of displaying video
• Internet: A reliable, high-speed internet connection (broadband or cellular data). A minimum speed of 10 Mbps download and 5 Mbps upload is recommended for optimal video quality.
• Camera and Microphone: A functioning camera and microphone, either built into your device or connected externally. You must allow the telehealth platform to access your camera and microphone.
• Browser or App: A current, supported web browser (such as Chrome, Safari, Firefox, or Edge) or the designated telehealth application, as specified in your appointment confirmation email.
• Environment: A private, quiet, and well-lit location where you can speak freely and be clearly seen and heard by your provider.

7. Emergency Protocols

8. Provider Credentials

Your telehealth consultations may be conducted by the following provider:

Telehealth consultations may also be conducted by qualified nurse practitioners or other licensed healthcare providers under the supervision of Dr. Bertrand R. Desilva. You will be informed of the provider conducting your visit at the time of scheduling.

9. Recording and Documentation

Your telehealth visit will be documented in your medical record in the same manner as an in-person visit. Regarding recording:

• Telehealth visits are not recorded by our practice unless expressly agreed upon by both parties in advance.
• You may not record the telehealth session (audio or video) without the prior written consent of your provider.
• Clinical notes, diagnoses, treatment plans, and prescriptions will be documented in your electronic health record as part of standard medical practice.

10. Financial Responsibility

By consenting to telehealth services, you acknowledge and agree to the following financial terms:

• Payment: Full payment for your telehealth consultation is required at the time of booking. We accept major credit cards and debit cards.
• Fee Transparency: Our consultation fees are clearly displayed on our website. You will know the exact cost of your visit before booking.
• Insurance Reimbursement: We may provide a detailed receipt or superbill that you can submit to your insurance company for potential out-of-network reimbursement. We do not guarantee that your insurance will reimburse you for telehealth services.
• Additional Services: Diagnostic tests (such as home sleep tests), durable medical equipment (such as CPAP machines), and prescriptions are not included in the consultation fee and may involve separate charges from third-party providers or suppliers.

11. Consent Acknowledgment

Contact Information

If you have questions about this consent form or our telehealth services, please contact us: