Consent for Treatment
Please indicate approval and understanding before starting a telehealth visit with the TeamHealth VirtualCare health care provider.
Telehealth services offered by TeamHealth VirtualCare (“Group”), and the Group’s engaged providers (the “Providers” or “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).
Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “I,” “me,” or “my”) concerning the treatment methods, risks, and limitations of using telehealth and a telehealth platform.
In providing the Services, Group will utilize the Virtual Urgent Care Platform licensed and supported by Zipnosis, Inc. (“Zipnosis”). Zipnosis does not provide the Services; it performs administrative, payment and other supportive activities for Group and the Providers.
Consent for Treatment:
I will have a chance to consider, discuss and/or refuse the care recommended by the Provider. Providers cannot guarantee specific results. In order to provide this care, the Provider will rely on the information I provide about my health and any particular health conditions, including genetic information such as family health history.
The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:
- Appointment scheduling;
- Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between the Provider and me via:
- asynchronous and/or store-and-forward communications;
- two-way interactive audio; and/or
- two-way interactive audio and video interaction;
- Treatment recommendations by the Provider based upon such review and exchange of clinical information;
- Delivery of a patient treatment summary with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant; and/or
- Other electronic transmissions for the purpose of rendering clinical care to you.
I understand the use of telehealth can:
- Improve access to care by enabling me to remain in my preferred location and reduce the need for travel while the Provider consults with me. Telehealth services are available 24 hours a day, 7 days a week.
- Provide convenient access to follow-up care. If I need to receive non-emergent follow-up care related to my treatment, I can contact a VirtualCare Client Success Specialist at (855) 606-0777, 24 hours a day, 7 days a week to get access to the Provider or I can start a new telehealth visit.
- Reduce cost and improve access to limited services and to care management.
- Provide more efficient care evaluation and management. If I have questions related to my treatment or the functionality of telehealth services, I understand that I may also reach out via email to the VirtualCare Client Success Specialist at VirtualCare_Client_Success@teamhealth.com. I will receive a response to my email, electronic message, or other communication transmitted via telehealth technologies within 24 hours or the next business day if over a weekend or holiday.
- Allow me, as the patient, to obtain the expertise of a distant health care provider or specialist.
- The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and the Provider will make that determination.
- 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.
- I acknowledge that THE providers do not address medical emergencies. If I believe I AM experiencing a medical emergency, I should dial 9-1-1 and/or go to the nearest emergency room. I understand that I should not attempt to contact GROUP, ZIPNOSIS, a VIRTUALCARE CLIENT SUCCESS SPECIALIST, OR the Provider.
- I acknowledge that the Providers are an addition to, and not a replacement for, a local primary care provider. Responsibility for my overall medical care should remain with my local primary care provider, if I have one, and it is strongly suggested that I locate one if I do not.
- Group does not have any in-person clinic locations.
The Zipnosis technology platform 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. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).
I understand that, as with any health care service, there are potential risk associated with the use of telehealth. These risks may include, but are not limited to:
- Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, including but not limited to the disconnection of the technology during a telehealth consult. If this occurs I may be contacted by the Provider by phone or other means of communication.
- In rare events, the Provider may determine that the transmitted information is not sufficient (e.g., poor resolution of images) to allow for appropriate health decision making.
- In rare events, security protocols could fail, causing a breach of privacy of personal medical information.
- In rare events, a lack of access to complete health care records may result in clinical judgment errors by the Provider, including but not limited to adverse drug interactions or allergic reactions.
Assignment of Benefits/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 for services provided. 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. By accepting this form, I agree that Group, or Zipnosis, and its associates, employees, representatives, affiliates and vendors—including Group’s designated billing entity, collection agencies, and debt collectors—may deliver or cause to be delivered to me, at the telephone number(s) and e-mail address(es) I have provided or that are otherwise associated with my account, calls, text messages and e-mails for any purpose, including, but not limited to, statements, bills, payment receipts, commercial electronic mail messages, information regarding new services, and called advertisements or telemarketing messages made using an automatic telephone dialing system or artificial or prerecorded voice and commercial electronic mail messages. The purposes for which Group may contact me specifically include, but are not limited to, account-related issues, account verification, billing, payment, and debt collection.
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 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.
Passive Tracking Mechanisms:
Group utilizes Google Analytics which provides statistics and analytical tools used for search engine optimization and marketing purposes.
- teamhealthvirtualcare.com (Marketing website) – utilizes Google Analytics to track:
- Where audiences are coming from
- What audiences do on different pages
- Metrics may include sessions, page views, bounce rates, and entrances
- visit.teamhealthvirtualcare.com (Zipnosis platform) – tracking is limited to Google Tag Manager to track:
- Which URL users went to
By accepting this form, I further acknowledge, understand, and agree to the following:
- 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 I must be eighteen (18) years of age or older to receive treatment via telehealth unless accompanied in person by a parent or legal guardian.
- I understand and acknowledge that I will be asked to verify my identity as a condition of treatment via telehealth, which may include a government issued photo identification.
- I understand and acknowledge that my interactions with the Provider will establish a provider patient relationship and that my visit information will result in the creation of a medical record with the Group.
- Prior to the telehealth visit, I have been given access to the Provider’s credentials and I have elected to visit with the next available provider from Group.
- I understand that a full list of the Providers, along with their credentials, is available to view at https://www.teamhealthvirtualcare.com/directory/.
- I understand that I have the right to select an alternate to the next available Provider and there could be a delay in service while the alternate Provider is notified.
- I understand that the name and credentials of the Provider responsible for my treatment will be recorded in my treatment summary.
- I understand that I may access my treatment summary through Zipnosis at any time after my telehealth visit.
- If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and the Provider is not able to connect me directly to any local emergency services.
- I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.
- I understand that the use of telehealth services is voluntary. I have the right to refuse this telehealth consultation or withhold or withdraw my consent to the use of telehealth at any time without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled or affecting my right to future care or treatment.
- 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 in accordance with applicable law and Group policies.
- Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
- Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for Group’s health care operations.
- Unless otherwise authorized by this consent and/or state or federal law, I understand that my consent will be obtained before forwarding my medical record or any other patient-identifiable information to a third party.
- Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.
- In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of the Provider.
- Persons may be present during the telehealth visit other than the Provider who will be participating in, observing, or listening to my consultation with the Provider (g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role and this individual will be properly trained and required to keep my personal health information confidential. Further, I understand 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.
- I understand that I have a right to privacy and my selection of a location to receive telemedicine services in private or public environments is at my discretion.
- I understand that my telehealth consultation will not be recorded.
- I understand that I am responsible for identifying all individuals present at my location during the telehealth consultation and for confirming that I consent for those individuals to hear and have access to my personal health information.
- The Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
- I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Group at: VirtualCare_Records@teamhealth.com A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
- I understand there is value in having a primary care physician and/or a primary care medical home and that in-person medical treatment may be recommended in lieu of telehealth services on an annual or bi-annual basis.
- It is necessary to provide the Provider a complete, accurate, and current medical history. I understand that I can log into my “Portal” at any time to access, supplement, amend, or review my health information.
- There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of the Provider. If the Provider issues a prescription, I have the right to select the pharmacy of my choice.
- I understand that the Provider will not prescribe controlled substances.
- There is no guarantee that I will be treated by a Provider. The Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of the Provider, the provision of the Services is not medically or ethically appropriate and instead may recommend that I seek a different modality of care.
- I understand there is a risk of technical failures during a telehealth encounter that may be beyond the control of the 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.
- I have read and understand the information provided. I consent to services provided by TeamHealth VirtualCare.
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 OR THEIR RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, CONTRACTORS, AGENTS, MEMBERS, 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 (OR ANY OF THEIR AFFILIATES) 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. EXCEPT IN CASES INVOLVING FINANCIAL HARDSHIP OF THE PATIENT (OR PATIENT’S REPRESENTATIVE), 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.
IN THE EVENT ANY PROVISION OF THIS AGREEMENT IS HELD TO BE UNENFORCEABLE FOR ANY REASON, THE UNENFORCEABILITY THEREOF SHALL NOT AFFECT THE REMAINDER OF THIS AGREEMENT, WHICH SHALL REMAIN IN FULL FORCE AND EFFECT AND ENFORCEABLE IN ACCORDANCE WITH ITS TERMS.
BY ACCEPTING THIS FORM, I ACKNOWLEDGE THAT I AM GIVING UP MY RIGHT TO A JURY OR COURT TRIAL ON ANY MEDICAL MALPRACTICE CLAIM WITH RESPECT TO SERVICES THROUGH TEAMHEALTH VIRTUALCARE.
STATE SPECIFIC ADDENDUM
Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Arizona: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Arkansas: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website and the board’s address and phone number can be found here.
California: NOTICE TO PATIENTS: Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email: firstname.lastname@example.org, or call (800) 633-2322.
NOTICE: Nurse practitioners are licensed and regulated by the Board of Registered Nursing (916) 322-3350;
Iowa: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Idaho: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Indiana: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Kentucky: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Maine: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here; Or, the Maine Board of Osteopathic Licensure’s website, here.
For Maine Medicaid beneficiaries, MaineCare will pay for the Member’s transportation to MaineCare Covered Services pursuant to Section 113 of the MaineCare Benefits Manual (“Non-Emergency Transportation Services”).
Michigan Medicaid: I have been informed that Michigan Medicaid beneficiaries should use telemedicine primarily when travel is prohibitive or there is an imminent health risk justifying immediate medical need for services.
Oklahoma: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here; Or, the Oklahoma Board of Osteopathic Examiners’ website, here.
Rhode Island: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here.
Texas: I have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.
AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us
Vermont: I have been informed that if I want to register a formal complaint about a Provider, I should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here.