We are offering telemedicine in accordance with the emergency measures implemented by the US and Texas government.  Please note this is an emergency measure for 120 days from March-May 2020.  We are currently using the website called Doxy.me for our visits as it is easy to use.  There is nothing for you to download and the site is HIPPA compliant.  Please call us to schedule an appointment time and then you can enter the waiting room when notified by the office staff.  You can type the following into the web browser on your phone or your computer.    You will type your name and allow access to audio and video.

https://doxy.me/tamistoutmd

Informed Consent to Telemedicine Consultation

I have been asked by my healthcare provider to take part in a telemedicine consultation with

Tamara Stout, M.D, P.A who has deemed the virtual visit necessary to assist in my continuing medical care.

I understand the following:

1. The purpose is to assess and treat my current and chronic medical conditions.

2. The telemedicine consult is done through a 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 consultant practices in a different location and does not have the opportunity to meet with

me face-to-face, she must rely on information provided by me or my onsite healthcare providers if in a nursing home/assisted living environment. Dr. Stout can not be responsible for advice, recommendations and/or decisions based on incomplete or inaccurate information provided by me or others.

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 know there are potential risks with the use of this new technology. These include but are 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

 Electronic tampering.

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

7. I understand that I need to be able to provide as many vitals as possible to provide Dr. Stout with needed information to contribute to her decision making and my care management.  It is my responsibility to obtain these vitals with home access to a scale, thermometer, or blood pressure device.

8.  I understand that further information may be needed to adequately evaluate my current medical conditions such as labs or radiology and will not hold Dr. Stout at fault if decisions are made without this information.  I understand that I can go to a laboratory or Dr. Stout's office to have these done at any time.

9.  I understand that Dr. Stout may deem that it is my best interest to end the telehealth visit and request that I come in for a formal physical exam to further evaluate my medical concerns.

10. I understand that my insurance will be billed as if this were a normal in office visit and that I am responsible for any costs not covered by my insurance provider which includes my co-pays or deductible.  

11. I understand I can make a complaint of my provider to the Texas Medical Board by going online at

http://www.tmb.state.tx.us/page/place-a-complaint or calling the Complaint Hotline at 800-201-9353.

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

I certify that this form has been fully explained to me and I have had the opportunity to ask questions. 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 and understand by entering the doxy.me platform with Dr. Stout that this also implies my consent and I can stop the visit at any time.