Informed Consent For Telemedicine

I understand that the telemedicine uses electronic communications to enable and allow health care providers at different locations to share individual patient medical information for the purpose of providing and improving patient care and treatment.  Gokultel’s providers may include primary care physicians, specialists, and/or subspecialists.

I hereby authorize Gokultel, LLC (“Gokultel”), and Gokultel staff and associates (collectively the “Gokultel Personnel”) to examine and evaluate my medical condition and, based on the findings of that examination and evaluation, to provide medical therapies and treatments to me that may be deemed medically necessary for my disease or condition including prescriptions, including use of generic medications.

I understand that as part of my examination, evaluation and ongoing treatment, I may be expected to give blood and possibly other bodily specimen for testing by a licensed clinical laboratory; and understand that Gokultel Personnel will refer me to a licensed clinical laboratory to collect those specimen from me, to submit them for testing, and to obtain and send the results to Gokultel.

I understand that the therapies and treatments provided, performed or prescribed by Gokultel Personnel are not covered or reimbursed by Medicare or other insurance, and I agree to pay for all services myself. I understand that I will not be reimbursed by Medicare or my insurance company and Gokultel will not submit for reimbursement from Medicare or any insurance company on my behalf. I understand that payment is due when services are rendered, and if I should incur a balance for services rendered, I shall promptly pay the balance in full by cash, check or credit card.

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.

2. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.

6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection.

7. 7 I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in a language in which I understand

1. I fully understand that there is no guarantee with respect to the benefits that I may or may not realize from the therapies and treatments referred to above and recommended by Gokultel Personnel.

I have read this Consent to Treatment and have had the opportunity to have all of my questions answered by Gokultel Personnel with respect to the treatments and therapies referred to above and recommended by Gokultel Personnel.