Conditions of Treatment for a Telemedicine Visit
I hereby consent to receiving treatment via Primary Care Health Clinic provider or a qualified member of this healthcare team. I understand that “telemedicine” is the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care. I understand that telemedicine also involves the communication of my medical information, both orally and visually, to health care providers located at Primary Care Health Clinic.
I understand that I have the following rights with respect to telemedicine:
- I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. I understand that receiving treatment through telemedicine does not mean I cannot receive in- person health care services, either today or in the future. I understand that there are limitations to the types of treatment that can be appropriately provided via telemedicine, and that my provider determines whether or not it is appropriate for me to receive treatment via telemedicine.
- The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to reporting child, elder, and depending adult abuse, expressed threats of violence towards an ascertainable victim, and where I make my physical, mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to other entities shall not occur without my written consent.
- I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured. I also understand that there are risks involved in receiving treatment via telemedicine, such as interruption of the audio-video connection between me and my provider, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider; or delays in receiving medical treatment because of technological failures.
- I understand that I have a right to access my medical information and copies of medical records in accordance with California and federal law.
- I understand that I can discuss any questions that I have with my provider at the beginning of my telemedicine consult, that my provider will answer any such questions, and that I may decline to continue the telemedicine consultation at any time.
In addition to the above, I agree to the following conditions with respect to telemedicine:
- I assign and authorize direct payment to Primary Care Health Clinic of all insurance and health plan benefits payable for these services at a rate not to exceed actual charges. I understand and agree that I am responsible for all facility and physician bills for services rendered to me that are not paid by my insurance or health plan, if applicable, and as permitted by state and federal law. I understand that I may be eligible for aid in accordance with Primary Care Health Clinic’s financial assistance policies, as permitted under state and federal law. If any account is referred to an attorney or collection agency for collection, I will pay actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at the legal rate, unless prohibited by law.
- I understand that all physicians providing services to me during video visits are not employees or agents of Primary Care Health Clinic for clinical purposes and that they are independent contractors. These physicians may bill separately for their services. I understand that I am under the care and supervision of my attending physician.
- Audio or video recording of the video visit is strictly prohibited, and Primary Care Health Clinic does not consent to any such recording.
- By beginning my telemedicine consult, I confirm that I have read and understand the information in this document, that my name and identity have been correctly identified, that I agree to the above conditions, and I agree to receive treatment via telemedicine.
