Patient Consent Form

Introduction 

Teledermatology is the delivery of dermatological services using technology when the dermatologist and patient are not in the same physical location. Electronically transmitted information may be used for diagnosis, treatment, follow-up, and/or patient education, and may include use of any of the following: 

• Patient medical records
• Medical images
• Interactive audio, video, and/or data communications and/or 
• Output data from medical devices, sound and video files. 

The interactive electronic systems used by Skinsage incorporates network and software security protocols to protect the confidentiality of your patient information and your imaging data, and includes measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. 

With your consent, and as described in greater detail below, your electronically transmitted information may be de-identified and used for research, development and educational purposes.  There is a chance that some commercial value may result from the use of your information. If that should happen, you will not be offered a share in any profits.  

Potential Benefits and Risks of Teledermatology: 

The potential benefits of teledermatology include improved access to dermatological care, including access to specialized care, as well as the ability to communicate directly with your dermatology provider. 

As with any medical procedure, there may be potential risks associated with the use of telemedicine, including teledermatology. These risks include, but may not be limited to:

• Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by your dermatological provider or specialist. 
• Depending upon your condition and needs, your dermatological provider may not be able to provide medical treatment to you using telemedicine equipment, nor provide for or arrange for any emergency care that you may require. 
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment. 
• Security protocols could fail, causing a breach of privacy of your confidential medical information. 
• A lack of access to complete medical records may result in errors in medical judgment. 

By accepting you acknowledge and agree to the following:

• I have read, understand, and agree to Skinsage’s Privacy Policy and Terms of Use, and understand that by using Skinsage’s services, I am consenting to comply with the terms of each. 
• The laws that protect the privacy and confidentiality of medical information also apply to telemedicine. Information obtained during a telemedicine encounter, which identifies me, should not be disclosed to any third party without my consent except for the purposes of treatment, payment and healthcare operations. 
• Telemedicine may involve electronic communication of my confidential medical information to other medical providers who may be located in other areas, including out-of-state. 
• With my consent, my medical information may be used on a de-identified basis for the purposes of medical outcomes research by dermatological providers using the Skinsage platform. This may include certain de-identified information from my electronic health records, including demographic data and treatment and diagnostic information, as well as imagines I have uploaded to the Skinsage platform. 
• Skinsage is not intended for use in emergency situations, and I will contact 911 if I am in need of emergency medical care. 
• I have the right to withdraw my consent to the use of telemedicine during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment, nor will it subject me to the risk of loss or withdrawal of any health benefits to which I am otherwise entitled. 
• I have the right to inspect all information obtained and recorded during the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee. Such inspection and copying of records shall be subject to my dermatological provider’s office policies and procedures. 
• I may expect the anticipated benefits from the use of telemedicine in my care, but I understand that no results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse. 
• I understand that my condition may require a referral to a specialist for further evaluation and treatment. 
• A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My dermatological provider has explained the alternative care methods to my satisfaction. 

Patient Consent to the Use of Telemedicine 

I have read and understand the information provided above regarding telemedicine, have discussed it with my dermatological provider 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 care. I hereby consent to and authorize Skinsage to receive, store, use and disclose my information for telemedicine in the course of my diagnosis and treatment.

Patient Consent to the Use and Disclosure of De-identified Medical Information for Medical Outcomes Research 

I hereby give my informed consent for the use and/or disclosure of my de-identified medical information for the purposes of medical outcomes research by Skinsage and/or dermatological providers using the Skinsage platform. I understand that my de-identified medical information used and/or disclosed for medical outcomes research purposes may include certain information from my electronic health records, including demographic data and treatment and diagnostic information, as well as photos or other images I have uploaded to the Skinsage platform. I understand that I can revoke my consent at any time, except to the extent that my information has already been used and/or disclosed in reliance on this consent prior to such revocation.  I understand that the use of my de-identified medical information for research purposes may result in commercial value, but that I will not share in any such profits.