Consent To Treat

Introduction:

Telemedicine care consults and assisted telemedicine care consults involve the use of electronic communications and other technology to enable health care providers at a different location than the patient to evaluate, diagnose, treat, provide opinion, follow-up and/or educate the patient. On-location care consults (in- person care, house call) involves medical care via an in-person evaluation directly at the site of where the patient is located, outside of a physician’s medical office or hospital. These health care providers may be physicians, nurse practitioners, physician assistants, dietitians, physical therapists, among other licensed professionals (“Healthcare Provider(s)”).

Electronically transmitted information may be used in all services provided. The technology and information that may be utilized include any/all of the following: medical records, medical images, live two-way audio and video, email, cellular phones, output data from medical devices or apps, sound or video files, and other forms of telecommunication.

The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient health information and will include adequate administrative, physical, and technical measures to safeguard the data and to protect the data from potential risks and intentional or unintentional corruption.

Risks of Telemedicine:

There may be potential risks associated with the use of telemedicine. Risks include, but are not limited to:

Risks of On-Location Care Consults (House-calls):

There may be potential risks associated with the use of on-location care consults. Risks include, but are not limited to:

By Checking the Box(Signing, Acknowledging) for this document, I understand and agree to the following:
  1. I wish to engage Care on Location, PC, for a consultation with a Healthcare Provider. 

  2. Laws that protect privacy and confidentiality of medical information for in-person care also apply to telemedicine, and that no information obtained which identifies me will be disclosed without my consent, except as permitted by law. 

  3. I have the right to withhold or withdraw consent to care during the course of that care at any time, without affecting my right to future care or treatment. 

  4. I have the right, within the constraints of the law, to inspect information obtained and recorded in the course of a telemedicine or in-person interaction, and receive copies of this informational for a reasonable fee and in accordance with Care on Location, PC’s standard policies and practices. 

  5. I understand that telemedicine and in-person care may involve electronic communication of personal health information to other medical practitioners who may be located in other areas, including out of state. 

  6. I understand that there are certain benefits to using telemedicine or in-person care, but that no results can be guaranteed or assured. My condition may not be cured or improved, and in some cases, may get worse. 

  7. Health Care Providers are limited in their clinical liability towards me for telemedicine consults or on-location care consults as circumstances may not be optimal or complete. I agree to not hold Care on Location, PC or any of its Healthcare Providers liable for opinions, diagnostic or therapeutic, provided based on these consultations. 

  8. There may be a delay in arranging an appointment either for telemedicine consults or on-location care consults, and access to care is not guaranteed. 

  9. I have the right to seek alternative forms of healthcare at any point in time, including during a telemedicine or on-location care consultation. These alternative forms may include going to a clinic, doctor’s office, urgent care, emergency room, or any other care provider that I feel may be able to address my medical situation. Additionally, I may elect to call my own personal healthcare provider to seek guidance. 

  10. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, at a testing facility, or at the direction of a Healthcare Provider. 

  11. I understand that others non-medical personnel may be present during my encounter. They are also required to maintain confidentiality of my information. I will be informed of their presence and be given the right to request: (i) omission of specific details of medical history/physical exam that are deemed sensitive to me; and (ii) termination of the consultation at any time. 

  12. I understand that other Care on Location, PC professional personnel may be present on a live video feed during my encounter. They are also required to maintain confidentiality of my information. I will be informed of their presence and be given the right to request: (i) omission of specific details of medical history/physical exam that are deemed sensitive to me; and (ii) termination of the consultation at any time. 

  13. I understand that a bill may occur both from the telemedicine service provider AND a facility fee may be charged from the site at which I was located at the time of a consult (for example nursing home, hospital, dialysis center, etc.) 

  14. I have read and understood the information provided regarding telemedicine, and all of my questions have been answered. If I do not understand, I have the right to seek answers to my questions to my level of satisfaction prior to engaging in the interaction. 

  15. I am authorizing Care on Location, PC’s Healthcare Providers to provide me with their observations, treatments, and recommendations regarding my medical condition. 

  16. I understand that my condition may require a referral to a specialist for further evaluation and treatment. 

  17. On Care Location, PC and its Healthcare Providers may refuse telemedicine service or on-location care consults in the event such visits are impracticable or not helpful to me in On Care Location, PC’s sole discretion. On Care Location, PC and its Healthcare Providers do not assume primary responsibility for me as a patient and may not have the ability to see me at all times (such as nights or weekends) or respond to my immediate medical needs. IN THE EVENT OF AN EMERGENCY, SEEK MEDICAL TREATMENT FROM A PRIMARY PHYSICIAN OR HOSPITAL IMMEDIATELY. 

By Checking the Box (Signing, Acknowledging) this “INFORMED CONSENT TO TREAT”, I hereby state that I have read, understood, and agree to the terms of this document.