Informed Consent/Consent for Treatment

Please indicate your approval and understanding before starting your telehealth visit with the TeamHealth VirtualCare (“Group”) health care provider.  Telehealth involves the use of electronic communications, information technology or other electronic means for the purpose of treatment or patient care who are in different locations from the health care provider.

 

I ACKNOWLEDGE THAT TELEHEALTH IS NOT DESIGNED OR INTENDED OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENCY, OR LIFE-THREATENING MEDICAL CONDITIONS AND SHOULD NOT BE USED IN THOSE CIRCUMSTANCES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 911 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

 

I acknowledge that I am located in the state selected at the time I start this telehealth visit.

 

I understand and acknowledge that I must be eighteen (18) years of age or older to receive treatment via telehealth unless accompanied in person by a parent or legal guardian.

 

I understand and acknowledge that I will be asked to verify my identity as a condition of treatment via telehealth, which may include a government-issued photo identification.

 

I understand and acknowledge that my interactions with the Group provider will establish a provider-patient relationship and that my visit information will result in the creation of a medical record with the Group.

 

I acknowledge that I have agreed to the Terms of Service and that I understand the Privacy Policy.

 

Consent for Treatment:

 

I will have a chance to consider, discuss and/or refuse the care recommended by the Group provider. Group providers cannot guarantee specific results. In order to provide this care, my Group provider will rely on the information I provide about my health and any particular health conditions, including genetic information such as family health history.

 

Expected Benefits of Telehealth:

 

I understand that the use of telehealth can:

  • Reduce the need for travel to a distant consultation site;
  • Reduce cost and improve access to limited services and to care management; and/or
  • Allow me, as the patient, to obtain the expertise of a distant health care provider or specialist.

 

Potential Risks of Telehealth:

 

I also understand that, as with any health care service, there are potential risks associated with the use of telehealth.  These risks may include, but are not limited to:

  • In rare instances, information transmitted as part of a telehealth encounter may not be sufficient (e.g., poor resolution of images) to allow for appropriate health care decision making by the Group provider;
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of telehealth equipment, including but not limited to the disconnection of the technology during a telehealth consult. If this occurs, you may be contacted by the Group provider by phone or other means of communication;
  • I understand that in rare instances, security protocols could fail, causing a breach of privacy of my personal health information; and/or
  • In rare instances, a lack of access to complete health care records may result in clinical judgment errors by the Group provider, including but not limited to adverse drug interactions or allergic reactions.

 

Assignment of Benefits and Financial Responsibility:

 

I assign all medical or insurance benefits to which I am entitled, including governmental sponsored programs such as but not limited to Medicare or Medicaid, private insurance and other health plans to the Group. I hereby authorize said Group to release any and all information necessary to secure payment, which is to be issued directly to the Group for the services as described herein.

 

I understand that I am financially responsible for all fees and charges whether or not paid by insurance or other third party for services provided. I guarantee payment of all charges, copayments, deductibles and coinsurance amounts for services rendered to or on behalf of the named patient. If I fail to make payment as provided herein, I understand that affirmative collection action will be taken.  I further agree to pay all collection costs and attorney fees should the account become delinquent and referred to a collection agency/debt collector. By accepting this form, I agree that Group and its associates, employees, and representatives—including Group’s designated billing entity, collection agencies, and debt collectors—may deliver or cause to be delivered to me, at the telephone number(s) I have provided or that are otherwise associated with my account, calls and text messages for any purpose, including called advertisements or telemarketing messages made using an automatic telephone dialing system or an artificial or prerecorded voice.  The purposes for which Group may contact me specifically include, but are not limited to, account-related issues, account verification, billing, payment, and debt collection.

 

Medical Record:

 

I understand that the Group uses technology to create a medical record, which allows providers using this technology to store, update and use my health information when needed at the time I am seeking care. The Group’s use of technology allows better access to my health information.

 

I acknowledge that any Group provider who accesses my medical record may access and use my record as needed to provide treatment, including coordinating my care.

 

The Group will protect the privacy of my health information and will not use or disclose it except as permitted by law. The Group’s privacy policies are more fully described in the Notice of Privacy Practices, which is available for review and download here. I acknowledge receipt of the Notice of Privacy Practices and consent to the Group’s use and disclosure of my health information in accordance with its terms.

 

I agree that my consent for treatment will remain valid until I revoke (withdraw) it in writing or until the law states it has expired. Any records created prior to my withdrawal of such consent will be maintained by the Group in accordance with applicable law and Group policies.

 

I agree that by providing my e-mail address at any time, I consent to receiving information from the Group or Zipnosis, including, but not limited to, statements, bills, payment receipts, and information regarding new services at that email address.

 

I understand that the name and credentials of the Group provider responsible for my treatment will be recorded in my treatment summary.

 

I understand that my consent will be obtained before forwarding my medical record or any other patient-identifiable information to a third party.

 

I understand that I may access my treatment summary through Zipnosis at any time.

 

By accepting this form, I understand and agree to the following:

  1. I understand that the Group provider may determine that the telehealth services are not appropriate for some or all of my treatment needs, and accordingly, may elect not to provide the telehealth services and instead may recommend that I seek a different modality of care.
  2. I understand there is value in having a primary care physician and/or a primary care medical home and that in-person medical treatment may be recommended in lieu of telehealth services on an annual or bi-annual basis.
  3.  I understand that if someone other than the Group provider is present during the telehealth encounter, in order to operate the technology being used or to take notes, this individual will be properly trained and required to keep my personal health information confidential. Further, I understand that I will be informed of this individual’s presence in the telehealth consultation and that I have the right to request any or all the following: (1) the omission of specific details about my personal medical history or physical examination that are personally sensitive to me; (2) that, at any time, the non-medical personnel leave the telehealth examination room and/or (3) that, at any time, the telehealth consultation be terminated.
  4.  I understand that I am responsible for identifying all individuals present at my location during the telehealth consultation and for confirming that I consent for those individuals to hear and have access to my personal health information.
  5. I understand there is a risk of technical failures during a telehealth encounter that may be beyond the control of the Group provider, and I agree to hold harmless the Group and its affiliates, subsidiaries, and providers for delays in evaluation or for information lost due to such technical failures.
  6. I have read and understand the information provided. I consent to services provided by TeamHealth VirtualCare.

 

AGREEMENT TO ARBITRATE:

 

I UNDERSTAND AND AGREE THAT ANY DISPUTE RELATED TO THE TERMS OF THIS CONSENT TO TREATMENT, THE TELEHEALTH VISIT, INCLUDING BUT NOT LIMITED TO, CLAIMS OF MEDICAL MALPRACTICE, OR ANY OTHER CLAIMS ASSERTING THAT MEDICAL SERVICES RENDERED UNDER THIS CONTRACT WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPLETELY RENDERED, WHETHER BASED IN TORT OR CONTRACT, WILL BE DETERMINED BY SUBMISSION TO BINDING ARBITRATION AND NOT BY A LAWSUIT OR RESORT TO COURT PROCESS, EXCEPT AS STATE LAW PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS.  BOTH PARTIES TO THIS AGREEMENT, ARE GIVING UP THEIR CONSTITUTIONAL RIGHTS TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JUDGE OR JURY AND INSTEAD ARE ACCEPTING THE USE OF ARBITRATION.

 

IT IS THE INTENTION OF THE PARTIES THAT THIS AGREEMENT BIND ALL PARTIES WHOSE CLAIMS MAY ARISE OUT OF OR RELATE TO TREATMENT OF SERVICES PROVIDED BY THE GROUP AND ITS AFFILIATES, SUBSIDIARIES, AND PROVIDERS INCLUDING ANY SPOUSE OR HEIRS OF THE PATIENT AND ANY CHILDREN, SIBLINGS, REPRESENTATIVES, SUCCESSORS, AND ASSIGNS.  THE PARTIES FURTHER INTEND THAT THIS AGREEMENT IS TO SURVIVE THE LIVES OR EXISTENCE OF THE PARTIES HERETO.

 

ALL CLAIMS FOR MONETARY DAMAGES EXCEEDING THE JURISDICTIONAL LIMIT OF THE SMALL CLAIMS COURT OR $25,000, WHICHEVER IS LOWER, AGAINST THE GROUP OR THEIR RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, CONTRACTORS, AGENTS, MEMBERS, AFFILIATES, SUBSIDIARIES AND PROVIDERS MUST BE ARBITRATED INCLUDING, WITHOUT LIMITATION, CLAIMS FOR LOSS OF CONSORTIUM, WRONGFUL DEATH, EMOTIONAL DISTRESS OR PUNITIVE DAMAGES.  FILING OF ANY ACTION IN ANY COURT BY THE GROUP (OR ANY OF THEIR AFFILIATES) TO COLLECT ANY FEE FROM THE PATIENT, WHICH CLAIM IS NOT SUBJECT TO THIS AGREEMENT TO ARBITRATE, SHALL NOT WAIVE THE RIGHT TO COMPEL ARBITRATION OF ANY HEALTHCARE LIABILITY CLAIM.

 

A DEMAND FOR ARBITRATION MUST BE COMMUNICATED IN WRITING TO ALL PARTIES.  EXCEPT IN CASES INVOLVING FINANCIAL HARDSHIP OF THE PATIENT (OR PATIENT’S REPRESENTATIVE), EACH PARTY SHALL SELECT AN ARBITRATOR (PARTY ARBITRATOR) WITHIN THIRTY DAYS AND A THIRD ARBITRATOR (NEUTRAL ARBITRATOR) SHALL BE SELECTED BY THE ARBITRATORS APPOINTED BY THE PARTIES WITHIN THIRTY DAYS THEREAFTER.  EACH PARTY TO THE ARBITRATION SHALL PAY SUCH PARTY’S PRO-RATA SHARE OF THE EXPENSES AND FEES OF THE NEUTRAL ARBITRATOR, AS WELL AS THE FEES OF THE ARBITRATOR OF THEIR SELECTION, TOGETHER WITH OTHER EXPENSES OF THE ARBITRATION INCURRED OR APPROVED BY THE NEUTRAL ARBITRATOR, NOT INCLUDING COUNSEL FEES OR WITNESS FEES, OR OTHER EXPENSES INCURRED BY A PARTY FOR SUCH PARTY’S OWN BENEFIT. THE PANEL SHALL HAVE AUTHORITY TO REALLOCATE ARBITRATION FEES (BUT NOT ATTORNEY FEES) AS PART OF ITS FINAL AWARD IN THE PANEL’S DISCRETION.

 

THE PARTIES CONSENT TO THE INTERVENTION AND JOINDER IN THIS ARBITRATION OF ANY PERSON OR ENTITY WHICH WOULD OTHERWISE BE A PROPER ADDITIONAL PARTY IN A COURT ACTION, AND UPON SUCH INTERVENTION AND JOINDER, ANY EXISTING COURT ACTION AGAINST SUCH ADDITIONAL PERSON OR ENTITY SHALL BE STAYED PENDING ARBITRATION.

 

THE PARTIES AGREE THAT ARBITRATION UNDER THIS AGREEMENT SHALL BE CONDUCTED PURSUANT TO THE PROCEDURES SET FORTH BY THE AMERICAN HEALTH LAWYERS ASSOCIATION.  THE PARTIES AGREE THAT THE SUBSTANTIVE LAWS OF THE STATE WHERE THE PATIENT IS LOCATED AT THE TIME THE SERVICES IN DISPUTE ARE RENDERED SHALL GOVERN, INCLUDING THE SUBSTANTIVE AND PROCEDURAL LAW OF MEDICAL MALPRACTICE AND HEALTHCARE LIABILITY OF SUCH STATE.

 

IN THE EVENT ANY PROVISION OF THIS AGREEMENT IS HELD TO BE UNENFORCEABLE FOR ANY REASON, THE UNENFORCEABILITY THEREOF SHALL NOT AFFECT THE REMAINDER OF THIS AGREEMENT, WHICH SHALL REMAIN IN FULL FORCE AND EFFECT AND ENFORCEABLE IN ACCORDANCE WITH ITS TERMS.

 

BY ACCEPTING THIS FORM, I ACKNOWLEDGE THAT I AM GIVING UP MY RIGHT TO A JURY OR COURT TRIAL ON ANY MEDICAL MALPRACTICE CLAIM WITH RESPECT TO SERVICES THROUGH TEAMHEALTH VIRTUALCARE.

 

 

ADDENDUM

 

For Colorado residents:

(a) The patient retains the option to refuse the delivery of the services via telemedicine at any time without affecting the patient’s right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;

(b) All applicable confidentiality protections shall apply to the services;

(c) The patient shall have access to all medical information resulting from the telemedicine services as provided by applicable law for patient access to his or her medical records; and

(d) The patient has a right to privacy and his or her selection of a location to receive telemedicine services in private or public environments is at the patient’s discretion.

 

For Virginia residents:

(a) Telemedicine services are provided via electronic technology or media, including interactive audio or video, for the purpose of diagnosing or treating a patient (including, but not limited to prescription refills, appointment scheduling, and patient education), regardless of the originating site and whether the patient is accompanied by a health care provider at the time such services are provided;

(b) The use of telehealth services is voluntary and the patient may refuse the telehealth service(s) at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of the patient’s benefits;

(c) Dissemination, storage, or retention of an identifiable patient image or other information from the telehealth service(s) shall comply with federal laws and regulations and Virginia state laws and regulations requiring individual health care data confidentiality;

(d) The patient has the right to be informed of the parties who will be present at the distant (Provider) site and the originating (member) site during any telemedicine service and has the right to exclude anyone from either site; and

(e) The patient has the right to object to the videotaping or other recording of a telehealth consultation.

 

For Texas Residents:

NOTICE CONCERNING COMPLAINTS, Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.