My Health Africa (MHA) Telemedicine Standard Consent Form
Online telemedicine consultations involve the use of electronic communications to enable healthcare providers, including but not limited to, primary care practitioners, doctors, specialists, subspecialists, health professionals, medical institutions and hospitals (Healthcare Providers), to access personal information of those patients they consult with for diagnosis, therapy, follow-up, education and other purposes aimed at improving patient care.
- WARNING: Do not use telemedicine for any emergency cases. If in doubt visit your local hospital. Telemedicine is not suitable for all types of consultations. Do not use telemedicine if you think you will need an in person physical examination.
- LIMITATION OF LIABILITY: MHA only provides the Telemedicine Service to allow Healthcare Providers to communicate with patients. MHA does not provide medical advice. MHA accepts no liability for any advice, opinions treatment and prescriptions provided by Healthcare Providers. The Healthcare Providers providing advice, opinions, treatment, and prescriptions are wholly responsible for all their advice, opinions, treatments, and prescriptions. MHA will not be accountable or held responsible for such advice, opinions, treatments, and prescriptions.
- PURPOSE: By providing your consent under this consent form, you will gain access to MHA’s Telemedicine Service. **** Please note that if you give consent under this form and gain access to MHA’s Telemedicine Service you do not get the right to make, capture or use any images or audio recording of or from the telemedicine consultation with the Health Provider. You, the Healthcare Provider and MHA do not have the right to make, capture or use voice or video recordings of or from the telemedicine consultations.
- EXPECTED BENEFITS: Improved access to medical care by enabling a patient to remain in their locality while being able to consult with a Medical Provider.
- POSSIBLE RISKS: As with any medical consultations or procedures, there are potential risks associated with the use of online consultations. These risks include, but are not be limited to:
- Information transmitted by a patient may not be sufficient to allow for appropriate medical decision making by the Healthcare Provider;
- In rare cases, the Healthcare Provider may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consultation;
- Delays in medical evaluation and treatment could occur due to deficiencies, failures or connectivity of the devices and/or equipment used;
- In rare instances, security protocols may fail, leading to a breach of privacy of personal medical information;
- In rare cases, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors.
- E-PRESCRIPTIONS: MHA has created an e-prescription feature in its Telemedicine Service to allow Healthcare Providers to issue prescriptions to patients. MHA accepts no responsibility or liability for any prescriptions issued to patients by Healthcare Providers. The e-prescription feature is available in order for the Healthcare Providers to issue prescriptions to patients and to keep a record of the prescriptions issued. If you need clarification about prescriptions issued through the MHA e-prescription feature, please contact either your Healthcare Provider or MHA on email@example.com.
- TO GAIN ACCESS TO THE MHA TELEMEDICINE SERVICE YOU MUST PROVIDE YOUR CONSENT BY INDICATING THAT YOU UNDERSTAND EACH OF THE FOLLOWING (USE THE ACCEPT OR DECLINE BUTTONS TO SHOW IF YOU UNDERSTAND):
- I understand that a variety of alternative methods of medical care, such as booking an in-person appointment through MHA may be available to me, and that I may choose one or more of these at any time.
- I understand that telemedicine consultations may involve electronic communication, through the MHA chat or other means, of my personal medical information, medical records, medical scans, and other sensitive information to the Medical Providers.
- I understand that MHA does not provide medical advice and MHA accepts no liability for any advice, opinions treatment and prescriptions provided by Healthcare Providers.
- I understand that giving my consent under this form and gaining access to MHA’s Telemedicine Service does not give me the right to make, capture or use any images or audio recording of or from my telemedicine consultations with the Health Provider.
- I understand that there are limitations to the technology (including the chat feature) and the process of telemedicine consultations, including the potential for incomplete exchanges or losses of information.
- I understand that a face-to-face/physical consultation may still be necessary after the telemedicine consultation.
- I hereby consent to MHA processing my personal data and sensitive personal data in accordance with any relevant country’s data protection legislation.
- I understand the information above and consent to undergo online consultations with Healthcare Providers using MHA’s Telemedicine Service.