To the Patient: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for an identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing and/or consenting below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.
Telehealth Informed Consent
Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care, including but not limited to telemedicine, which involves the use of communications to enable health care providers at sites remote from patients to provide consultative services. Telehealth services also include remote monitoring, tele-pharmacy, prescription refills, appointment scheduling, regional health information sharing, and non-clinical services, such as education programs, administration, and public health. CareATC Medstaff, P.C. (“CareATC”) providers may include primary care practitioners, behavioral healthcare providers, nurse practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any combination of the following:
- Patient medical records;
- Medical images;
- Live two-way audio and video;
- Interactive audio; and
- Output data from medical devices and sound and video files.
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.
During the COVID-19 national public health emergency, in reliance on guidance and notices from the U.S. Department of Health & Human Services (“HHS”), CareATC may seek to communicate with patients, and provide telehealth services, through remote communications technologies that provide private communication between patients and medical professionals, but may not fully comply with the requirements of the Health Insurance Portability and Accountability Act (“HIPAA”) Rules. CareATC will continue to rely HHS guidance for as long as it remains valid. Examples of such remote communications may include, but are not limited to, Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Skype, or other non-public facing video chat applications connected to the patient’s or health care provider’s phone or computer.
Such methods of remote communication are available to allow health care providers to best service patients while minimizing in-person contacts and preventing the further spread of the COVID-19 novel coronavirus, but potentially introduce and carry privacy risks that exceed those of HIPAA-compliant technology vendors. CareATC is working concurrently with these vendors and others to ensure full technical compliance with HIPAA to the best of its ability and is enabling all available encryption and privacy modes when using such remote communications applications. You are highly encouraged to employ all methods of encryption and security to safeguard the privacy of your protected health information and instructed never to utilize a public-facing application or communication method to transmit or communicate private medical information or data.
Primary responsibility for your medical care should remain with your local primary care doctor, if you have one, as does your medical record.
Expected Benefits of Telehealth:
- Improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician.
- More efficient medical evaluation and management.
- Obtaining expertise of a specialist.
Possible Risks of Telehealth:
As with any medical procedure, there are potential risks associated with the use of telehealth. These risks may include, without limitation, the following:
- Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
- In rare events, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a face-to-face meeting with your local primary care doctor.
- In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
By checking the box associated with "Informed Consent" and utilizing the CareATC services, you acknowledge that you understand and agree with the following:
- I hereby consent to receiving CareATC’s services via telehealth technologies. I understand that CareATC and its consulting providers offer telehealth services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the CareATC provider to determine whether or not my needs are appropriate for a telehealth encounter.
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth; I have received the HIPAA Notice i.e. Notice of Privacy Practices which explains these issues in greater detail.
- I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that CareATC will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
- I understand that my healthcare information may be shared with others (including health care providers and health insurers) for treatment, payment, and healthcare operations purposes. Psychotherapy notes are maintained by clinicians but are not shared with others, while billing codes and encounter summaries are shared with others and with me. If I obtain psychotherapy from CareATC, I understand that my therapist has the right to limit the information provided to me if in my therapist's professional judgment sharing the information with me would be harmful to me.
- I further understand that my healthcare information may be shared in the following circumstances:
- When a valid court order is issued for medical records.
- Reporting suspected abuse, neglect, or domestic violence.
- Preventing or reducing a serious threat to anyone's health or safety.
- To a public health authority, such as the Centers for Disease Control (“CDC”) or a state or local health department, that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability. For example, CareATC may disclose to the CDC, a state public health authority, or local public health authority protected health information on an ongoing basis as needed to report all prior and prospective cases of patients exposed to or suspected or confirmed to have Novel Coronavirus (2019-nCoV).
- I understand there is a risk of technical failures during the telehealth encounter beyond the control of CareATC. I agree to hold harmless CareATC for delays in evaluation or for information lost due to such technical failures.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate access to the service at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that the CareATC member service specialists are not able to connect me directly to any local emergency services.
- I understand the alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the CareATC or CareATC’s consulting healthcare provider (e.g. labs or bloodwork).
- I understand video images and audio recordings of me may be captured and stored electronically. I understand that these recordings may be later viewed and used for purposes of evaluation and training, which may include CareATC non-physician personnel. I understand and consent to the use of these images and audio recordings for the telehealth consultation and, potentially, evaluation, education and training.
- I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the CareATC provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
- I understand that I will not be prescribed any Drug Enforcement Agency scheduled controlled substances nor is there any guarantee that I will be given a prescription at all.
- I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
- I understand that in the event of any problem with the website or related services, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will CareATC or any CareATC subsidiary or affiliate be liable in any way for the use of the telehealth services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that I will not hold CareATC, its subsidiaries or affiliates liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with your use of the website or secure portals whether under a theory of breach of contract, negligence, strict liability, malpractice or otherwise, even if we or they have been advised of the possibility of such damages.
- I understand that CareATC makes no representation that materials on this website are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use.
- Additional State-Specific Consents: The following consents apply to users accessing the CareATC website or secure portals for the purposes of participating in a telehealth consultation as required by the states listed below:
- Arizona: Guardian consents to verify his/her identity prior to performing a mental health screening or mental health treatment on a minor. AZ ST § 36-2272.
- Connecticut: I understand that my primary care provider may obtain a copy of my records of any telehealth interaction. CT Public Act No. 15-88 (2015).
- Iowa: I understand that as necessitated by the availability of resources in the community where services are delivered, telehealth may be used in delivering and coordinating interventions with appropriate providers for autism support, subject to the licensure of the participating provider. Iowa Code Ann. § 225D.2.
- Kentucky: I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I also understand that I have the right to object to the videotaping of the telehealth consultation. KY Admin. Regs. Tit. 907, 3:170.
- Maryland: I understand that I cannot request telehealth services to be conducted via correspondence only. Code of MD Reg. 10.41.06.04.
- Nebraska: I understand that I have the right to be informed of any party who will be present at the site during the telehealth consult and I have the right to exclude anyone from being present. I understand that any dissemination of identifiable images or information from a consult requires my express permission. I understand that I have the right to request an in-person consult immediately after the telehealth consult and I will be informed if such consult is not available. NE Revised Stat. 71-8505; NE Admin. Code Tit. 471, Ch. 1.
- Nevada: I understand that the transmission of any confidential medical information while engaged in telemedicine is subject to all applicable federal and state laws with respect to the protection of and access to confidential medical information. NV Rev. Stat. Ann. § 633.0165.
- Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services.
- Tennessee: I understand that I may request an in-person assessment before receiving a telehealth assessment.
- Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via CareATC does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. VT Stat. Ann. § 9361.
Patient Medical Consent and Consent to the Use of Telehealth
I have read and understand the information provided above regarding telehealth, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
I have read this document carefully and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telehealth visit under the terms described herein.
I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination and testing, and treatment, including by telehealth where appropriate, for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements, and consent fully and voluntarily to its contents.
By checking the Box containing “INFORMED CONSENT FOR MEDICAL AND/OR TELEMEDICINE SERVICES” I hereby state that I have read, understood, and agree to the terms of this document.