Please indicate approval and understanding before starting a telehealth visit with the TeamHealth VirtualCare health care provider.
Telehealth services offered by TeamHealth VirtualCare (“Group”), and the Group’s engaged providers (the “Providers” or “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).
Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “I,” “me,” or “my”) concerning the treatment methods, risks, and limitations of using telehealth and a telehealth platform.
In providing the Services, Group will utilize the Virtual Urgent Care Platform licensed and supported by Zipnosis, Inc. (“Zipnosis”). Zipnosis does not provide the Services; it performs administrative, payment and other supportive activities for Group and the Providers.
Consent for Treatment:
I will have a chance to consider, discuss and/or refuse the care recommended by the Provider. Providers cannot guarantee specific results. In order to provide this care, the Provider will rely on the information I provide about my health and any particular health conditions, including genetic information such as family health history.
The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
I understand the use of telehealth can:
The Zipnosis technology platform will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
I understand that, as with any health care service, there are potential risk associated with the use of telehealth. These risks may include, but are not limited to:
Assignment of Benefits/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, or Zipnosis, and its associates, employees, representatives, affiliates and vendors—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) and e-mail address(es) I have provided or that are otherwise associated with my account, calls, text messages and e-mails for any purpose, including, but not limited to, statements, bills, payment receipts, commercial electronic mail messages, information regarding new services, and called advertisements or telemarketing messages made using an automatic telephone dialing system or artificial or prerecorded voice and commercial electronic mail messages. 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.
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 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.
Passive Tracking Mechanisms:
Group utilizes Google Analytics which provides statistics and analytical tools used for search engine optimization and marketing purposes.
By accepting this form, I further acknowledge, understand, and agree to the following:
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.
STATE SPECIFIC ADDENDUM
Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Arizona: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Arkansas: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website and the board’s address and phone number can be found here.
California: NOTICE TO PATIENTS: Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email: email@example.com, or call (800) 633-2322.
NOTICE: Nurse practitioners are licensed and regulated by the Board of Registered Nursing (916) 322-3350;
Iowa: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Idaho: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Indiana: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Kentucky: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Maine: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here; Or, the Maine Board of Osteopathic Licensure’s website, here.
For Maine Medicaid beneficiaries, MaineCare will pay for the Member’s transportation to MaineCare Covered Services pursuant to Section 113 of the MaineCare Benefits Manual (“Non-Emergency Transportation Services”).
Michigan Medicaid: I have been informed that Michigan Medicaid beneficiaries should use telemedicine primarily when travel is prohibitive or there is an imminent health risk justifying immediate medical need for services.
Oklahoma: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here; Or, the Oklahoma Board of Osteopathic Examiners’ website, here.
Rhode Island: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Texas: I have been informed of the following notice:
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.
AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us
Vermont: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here.