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 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 of [state selected at the time of requesting visit] at the time I start this telehealth visit.

 

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. 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. I agree and authorize in order for the Group, its designated billing entity, or collection agencies/debt collectors to service my account or to collect any amounts I may owe, the Group may contact, call or text me by telephone at any cellular and/or residential telephone number associated with my account using artificial or prerecorded voice or auto dialer technologies for any permissible purpose, including but not limited to account-related issues, account verification, billing, payment, or 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 for a period defined by the Group.

 

I agree that by providing my e-mail address at any time, I consent to receiving information from Zipnosis, statements, bills, payment receipts, and marketing material for new services at that email address.

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

 

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 and its 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 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. 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.

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 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.
  3. 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.