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Patient Consent Form
By signing this form, I understand and agree with the following:
Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. These providers may include hospital physicians, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are part of my clinical care team. This information may be used for diagnosis, therapy, follow-up and/or education including the billing of the tele-health visit(s).
Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:
By agreeing to use the telehealth/telemedicine services, I am consenting to Envision Health Care sharing of my protected health information with my Primary Care Provider and/or other members of my healthcare team. I am consenting to Envision billing and receiving payment for the tele-health visit(s). I understand, agree, and expressly consent to Envision Health Care obtaining, using, storing, and disseminating as necessary information about me, including my image, as necessary to provide the telehealth/telemedicine services. Electronic systems used 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. Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinicians, patient, or care team. I hereby release and hold harmless Envision and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.
I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record. I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit. I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled. I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.
By signing this consent, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.
Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. These providers may include hospital physicians, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are part of my clinical care team. This information may be used for diagnosis, therapy, follow-up and/or education including the billing of the tele-health visit(s).
Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:
- Progress reports, assessments, or other intervention-related documents
- Videos, pictures, text messages, audio, and any digital form of data.
By agreeing to use the telehealth/telemedicine services, I am consenting to Envision Health Care sharing of my protected health information with my Primary Care Provider and/or other members of my healthcare team. I am consenting to Envision billing and receiving payment for the tele-health visit(s). I understand, agree, and expressly consent to Envision Health Care obtaining, using, storing, and disseminating as necessary information about me, including my image, as necessary to provide the telehealth/telemedicine services. Electronic systems used 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. Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinicians, patient, or care team. I hereby release and hold harmless Envision and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.
I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record. I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit. I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled. I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.
By signing this consent, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.