Expected Benefits: 1. Improved access to medical care by enabling a patient to occasionally remain in his/her home in New York State (or temporary home outside of New York State), or at an authorized New York State remote site, while the physician provides services through an authorized telemedicine software service, 2. More efficient medical evaluation and management, 3. Obtaining expertise of a distant specialist.

Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to: 1. In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); 2. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; 3. In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information; 4. In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors

By signing this form, I understand the following:


1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My care provider has explained the alternatives to my satisfaction.

5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

6. I understand that it is my duty to inform my care provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine, have discussed it with my psychiatrist and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical and/or health care. I hereby authorize Jonathan Tamaiev MD and Jonathan Tamaiev MD P.L.L.C to use telemedicine in the course of my diagnosis and treatment.