Authorization to Release Information

If I am a Patient I acknowledge and agree to the following:

      I hereby authorize the release of my protected health information that I provide through the PROCLE HEALTHWORKS program, including, but not limited to my demographic information, my symptoms, my health information as well as my images to the healthcare providers using the PROCLE HEALTHWORKS program. I hereby authorize PROCLE HEALTHWORKS to use and disclose such information as permitted by State and Federal Laws and for the purposes of treatment, share clinical information for education and to provide preventive care. I acknowledge and agree that I am waiving my privacy rights by submitting such information to PROCLE HEALTHWORKS and this information may be redisclosed. I understand and acknowledge that I may revoke the authorization by providing written notice to PROCLE HEALTHWORKS at 3555 Montwood Ct., Marietta, GA 30062 or email helpline@proclehealthworks.com, but the revocation only applies after the written revocation is received by PROCLE HEALTHWORKS. This authorization to use the information submitted shall last for so long as I maintain an account with PROCLE HEALTHWORKS and for two years thereafter.

    I acknowledge and agree that I am personally responsible for the security and privacy of my username and password to access PROCLE HEALTHWORKS.

    I hereby acknowledge and agree that I am over the age of 18 and voluntarily using the PROCLE HEALTHWORKS program for my own personal purposes.

For Morehouse Healthcare Users

In consenting to participate in a telemedicine consultation with a Morehouse Healthcare provider I and/or my designee will, through interactive audio/video connection, be able to consult with a Morehouse Healthcare provider about my condition. The Morehouse Healthcare provider/professional has explained to me how the telemedicine technology will be used to complete a consultation/treatment.

I understand there are potential risks with this technology:

  1. The video connection may not work or that it may stop working during the consultation.
  2. The video picture or information transmitted may not be clear enough to be useful for the consultation.
  3. I may be required to go to the location of the consulting physician if it is felt that the information obtained via telemedicine was not sufficient to make a diagnosis or if I need a higher level of where telemedicine may not be appropriate.

I also understand authorized staff who are required to assist with operation of video equipment may be present during the consultation. Reasonable steps will be taken to maintain confidentiality of any information obtained. I understand that a limited physical examination may take place during the videoconference and that I have the right to: (1) ask non-medical personnel to leave the examination room and/or (2) ask my healthcare provider to discontinue the conference at any time. I further understand that some parts of the exam may be conducted by individuals at my location at the direction of the consulting health care provider.

I authorize the release of any relevant medical information about me to the Morehouse Healthcare provider, other consulting health care provider, any staff the Morehouse Healthcare providers supervise, third party payers and other healthcare providers who may need this information for continuing care purposes.

I hereby release Morehouse Healthcare, its trustees, officers, directors, employees, and agents from any and all liability, which may arise from the taking and authorized use of such videotapes, digital recording films and photographs.

I have read this document carefully, understand the risks and benefits involved in a telemedicine health visit, had my questions explained to me, and hereby consent to participate in a telemedicine visit under the conditions described in this document.