Telemedicine Informed Consent

Patient name: __________________________________________

Date of birth: __________________ Date: __________________

When Haven may use telemedicine

Florida generally requires an in-person physical examination before an initial medical marijuana physician certification. A qualified physician who previously issued a certification to a patient after an in-person examination may conduct a subsequent certification renewal evaluation by telehealth when Florida law permits and the physician determines that telehealth is clinically appropriate.

A telemedicine appointment does not guarantee a certification. If an in-person examination, additional records, or testing is needed, the physician may postpone the decision or ask me to attend in person.

Location and participants

I will tell Haven my physical location at the start of each visit, provide a working callback number, and tell the clinician who else is present with me. Haven may decline or reschedule a visit if my location, the clinician's authority to provide care there, or the nature of the visit does not permit telemedicine.

Benefits, limits, and risks

Telemedicine can reduce travel and improve access to follow-up care. It may also limit what the clinician can observe or examine. Poor audio or video, missing records, or a technology failure may require an in-person visit or rescheduling. Electronic communications involve privacy risks despite reasonable safeguards.

I will try to join from a private location using a secure device. I may ask who is participating in the visit. Neither I nor Haven will record the visit without the consent required by applicable law.

Choices and urgent needs

Telemedicine is voluntary. I may decline it or ask to stop a visit and seek an in-person appointment. This may delay an evaluation or certification decision. Telemedicine is not an emergency service. For a medical emergency, I will call 911 or go to the nearest emergency department.

Records, privacy, and fees

Haven will document telemedicine services in my medical record. Its HIPAA Notice of Privacy Practices applies to my health information. Fees and any applicable insurance coverage will be explained under Haven's current payment terms; coverage is not guaranteed.

I have read this form, had the opportunity to ask questions, and voluntarily consent to telemedicine services when Haven determines they are appropriate and legally permitted.

Patient or authorized representative signature: ______________________________

Date: __________________

If signed by a representative

Printed name: _________________________________________________

Relationship and legal authority: _________________________________