I have been asked by my healthcare provider to take part in a telemedicine consultation with Rochester Endocrinology & Diabetes Center, Rochester Hills, Michigan,  and its physicians, associates, medical assistants and others deemed necessary to assist in my medical care through a telemedicine consultation.  I understand the following:

1. The purpose is to assess and treat my medical condition.
2. The telemedicine consult is done through a secure HIPPA compliant two-way video link-up whereby the physician or other health provider can see my image on the screen and hear my voice. However, unlike a traditional medical consult, the physician or other health provider does not have the use of the other senses such as touch or smell; and it may not be equal to a face-to-face visit.
3. Since the telemedicine consultants practice in a different physical location and do not have the opportunity to meet with me face-to-face, they must rely on information provided by me or my onsite healthcare providers.
4. I can ask questions and seek clarification of the procedures and telemedicine technology.
5. I can ask that the telemedicine exam and/or videoconference be stopped at any time.
6. I understand that just like any other remote communication technology there are potential risks such as but not limited to:

• Interruption of the audio/video link.
• Disconnection of the audio/video link
• A picture that is not clear enough to meet the needs of the consultation.

If any of these risks occur, the consultation might need to be stopped.

In order to participate in the telemedicine program, I agree to pay the necessary copay/coinsurance/deductible/self pay charges similar to that of an office visit based on my insurance coverage.

I, the undersigned patient, do hereby understand and state that I agree to the above consents.

I certify that this form has been fully explained to me. I have read it or have had it read to me. I understand and agree to its contents. I volunteer to participate in the telemedicine examination