Terms of Conditions and Informed Consent for Bluegrass Telemedicine, PLLC


Introduction: Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include Physicians, Physician Assistants, or Nurse Practitioners who are appropriately licensed in accordance with state regulations to practice medicine in the state of Kentucky.


By agreeing to these terms I understand and consent to the following:


  1. I hereby consent to video examination and treatment by Bluegrass Telemedicine, PLLC including diagnostic and/or therapeutic procedures ordered by the Provider. 

  2. I understand 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.

  3. 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. 

  4. I understand that I have the right to inspect all information obtained in the course of a telemedicine interaction, and my receive copies of this information within a reasonable amount of time. 

  5. 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. 

  6. I understand that telemedicine may involve electronic communication of my medical information to other medical practitioners who may be located in other areas, including out of state only as is directly necessary for my care. 

  7. I understand that it is my duty to inform the Provider of a full and accurate medical history so they can provide the best possible treatment. 

  8. I understand that I may expect treatment of my condition but that result cannot be guaranteed. 

  9. I understand that by participating in a telemedicine visit there are some natural limitations to the extent of physical examination and assessment of my condition which could lead to medical error and I am willing to proceed knowing this risk. 

  10. I understand that the payment made to the provider is non-refundable.