Leslie E. Lawrence, M.D.

6221 S. Claiborne Ave

Ste., #209

New Orleans, LA. 70125

Consent to Use Telemedicine

At the beginning of each telemedicine session, I will help Dr. Lawrence to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:

1. The practice of Leslie E. Lawrence, M.D. is in the State of Louisiana. Dr. Lawrence holds an active medical license by the State of Louisiana. Dr. Lawrence may not be able to prescribe medications for me when I am in ANOTHER STATE or COUNTRY. Further, Dr. Lawrence may not be able to aid me in an EMERGENCY SITUATION when I am in ANY OTHER STATE or COUNTRY. If I require medication, I may contact Dr. Lawrence. If I require emergency care, I may call 911 or proceed to the nearest hospital or emergency room for help.

2. I submit to the exclusive jurisdiction of the Louisiana state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by Dr. Lawrence will be brought solely and exclusively in Louisiana state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of Louisiana.

3. Dr. Lawrence believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.

4. If Dr. Lawrence believes at any time that another form of services (for example, a traditional in person consultation) would be appropriate, she may discontinue telemedicine services and schedule an in-person consultation with herself or refer me to a healthcare provider in my area who can provide such services.

5. I have the right to withdraw consent to the use of telemedicine services at any time and receive in- person healthcare services with Dr. Lawrence.

6. I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my Dr. Lawrence and understand there are limitations to the technology which may require an in-person evaluation.

7. I agree to have the necessary computer, equipment and internet access for my telemedicine communications. I also agree to arrange for a location with enough lighting and privacy and is free from distractions and intrusions during my telemedicine communications.

8. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by Dr. Lawrence to me will be encrypted during transmission and will be stored only by Dr. Lawrence or a service provider selected by my Dr. Lawrence. I understand the dissemination of any personal-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or Louisiana state law.

9. I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to “auto-remember” usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation. I hereby release my doctor from any damages and claims in the event of an unintentional disclosure of my private health information while communicating with my doctor through a telemedicine communication.

10. I understand no part of the encounter will be recorded without written consent.

11. I have the right to access my medical information and obtain copies of my medical records in accordance with Louisiana law.

12. I understand that telemedicine services provided to me will be billed to me through a secure online encrypted-platform, Stripe. Transaction fees are done by entering your credit card number on Stripe at time of payment. Stripe does not keep your credit card information and Dr. Lawrence cannot see your credit card number. I understand that Superbills will be provided for each telemedicine service to submit my own insurance claim.

13. I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with Dr. Lawrence and all my questions were answered to my satisfaction.

___________________________________

Patient’s Name

___________________________________ ________________

Patient’s Signature Date