Consent to Use Telemedicine | Evivia : Telemedicine

Informed Consent for Telehealth Services Agreement

Authorization and Consent to Participate in Telemedicine Consultation, Informed Consent to Treatment and Acceptance of Terms of Service

Telehealth involves the use of electronic communications to enable providers at different locations to share individual client information for the purpose of improving client care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for appointment scheduling, chart review, health information sharing, diagnosis, therapy, remote prescribing, follow-up and/or education, and may include any combination of the following: client health records, live two-way audio and/or live audio-video output data from health devices and sound and video files, text, messaging, transmission of medical images and/or data transfer.

Please indicate approval and understanding before starting any online forms, online visits, telemedicine consultations, and any or all telemedicine communications with a health care provider. I understand that if information in this form conflicts with the Terms of Service, the information in this form applies to all online visits, online consultations and any all communications with any health care provider through Evivia, Eviviacare.com or any of its affiliates.

Responsibility for your overall health care should always remain with your primary health care provider. Telehealth services are an addition and not a replacement to your regular primary health care provider.

I ACKNOWLEDGE THAT ONLINE VISITS OR ANY TELEMEDICINE COMMUNICATIONS ARE NOT DESIGNED OR INTENDED OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENCY, OR LIFE-THREATENING MEDICAL CONDITIONS AND SHOULD NOT BE USED IN THOSE CIRCUMSTANCES. IN THE EVENT OF AN EMERGENCY PLEASE DIAL 911.

I acknowledge that I will answer questions truthfully and that if I do not understand a question I will stop using all online forms, online visits, telemedicine consultations, and all telemedicine communications. I acknowledge and agree that I am solely responsible for ensuring that the information submitted for the visit is accurate, complete and current. I understand that the health care provider will rely on this information to diagnose and prepare a treatment plan for my medical condition and my failure to provide accurate, complete and current information may lead to a delay in my treatment or a misdiagnosis.

I acknowledge that during the COVID-19 emergency I may receive care from a health care provider licensed in a state other than where I am a resident.

I understand and acknowledge that my information that I provide through all communications will result in the creation of a visit record in the electronic medical record of the health care provider.

Electronic health record: all online visits use stored electronic health records. This allows health care providers using this record to store, update and use my health information when needed at the time I am seeking care. The electronic health record allows better access to my health information, leading to better coordination and quality of care. This shared electronic health record is a secure system.

I acknowledge that any care provider who uses the shared electronic record may access and use my health records as needed to provide treatment (including coordinating my care) and to improve the quality of care.

Anticipated Benefits of Telemedicine: improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician and more efficient medical evaluation and management.

Anticipated Risks of Telemedicine: I understand and consent to the risks associated with my use of the online visit. The likelihood risks associated with use of telemedicine is low. The communication systems used are secure and encrypted, and network and software security protocols are in place to protect the confidentiality of patient information.

Possible risks associated with telemedicine might include, but not limited to (1) information that I transmit through the online visit may be insufficient to allow for appropriate medical decision-making by the health care provider (e.g., poor resolution of transmitted images); (2) failures of equipment (e.g., servers, devices) or infrastructure (e.g., communications lines, power supply) that may cause delays in medical evaluation and treatment, or loss of information; and (3) privacy risks, such as unauthorized access to or disclosure of my personal information. I acknowledge that, although the online visit provider and its online visit vendor strive to prevent unauthorized access to or disclosure of information about me through encryption of information transmitted by the online visit and other security measures, we cannot guarantee that my use of the online visit and the information will be private or secure, and I consent to this risk.

I understand that the health care provider or I may require an in-person examination prior to or after diagnosing or establishing a treatment plan. The anticipated response time for electronic communications submitted through the online visit varies and I accept any risk associated with the response time, including a delay in obtaining medical care. I understand and acknowledge that a health care provider might refer me to an in-person health visit if it is felt that the in-person visit is more appropriate.

I understand that making a request for treatment by completing and submitting any of the online forms, sending online messages to a health care provider, paying for services, providing photos and/or initiating video chat does not create a duty of care or create a doctor-patient relationship.

I understand that the provider’s duty of care does not begin at the point of me answering questions or making payment or starting a video visit but at the point at which the doctor accepts the duty of care.

I understand that my health care provider or I can discontinue any visit or any communication if it is felt that the live two-way audio and/or live audio-video output data from health devices and sound and video files, text, messaging, transmission of medical images and/or data transfer is not sufficient to reach a diagnosis establish a treatment plan.

I understand my healthcare information may be shared with other health professionals through the use of interactive video, audio and/or telecommunications technology. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission. The above-mentioned people will all maintain confidentiality of the information obtained. Video, audio, and/or digital photo may be recorded during the online visit.

I further understand that my healthcare information may be shared in the following circumstances: a. when a valid court order is issued for medical records b. reporting suspected abuse, neglect, or domestic violence c. preventing or reducing a serious threat to anyone’s health or safety d. if the federal and/or state laws requires the health care provider to report health care related information.

I understand that it may become necessary to release your protected health information to financial parties, credit card entities, banks, and financig companies, to facilitate your payment.

Services that are preformed with a credit card, debit card, or financing third party are not eligible for payment challenges after services are provided.

I agree, by signing this form electronically, that I am irrevocably consenting Evivia LLC, its officers, employees, representatives, agents, third parties and/or independent contractors to use and disclose my protected health information to any credit card entity, bank, or financing company when they request such information to process an account and/or assist with payment.

Services rendered are non-refundable and are not eligible for payment challenges.

I have had the alternatives to online visit and telemedicine communications explained to me, and I am choosing to participate in an online visit. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider. I also understand that at my request or at the direction of my health care provider, I may be directed to “face-to face,” in-person services.

I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

I have had a direct conversation with my health care provider, during which I had the opportunity to ask questions in regard to my visit. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

I agree to be called, messaged, and/or e-mailed to provide my insurance/benefit plan coverage/third party payment and/or credit card information to pay for the online visit. I agree to be responsible and pay out-of-pocket full cost cost for the associated on-line visit via credit card or online payment. I agree to be charged a full price for the visit if I do not show up for my appointment.

I consent to treatment through remote examination. I will have a chance to discuss and / or refuse the care recommended by my health care provider. Providers cannot promise specific results. I have had a direct conversation with my health care provider, during which I had the opportunity to ask questions in regard to my visit in a language in which I understand. My questions have been answered and I have been advised of the risks, benefits and any alternatives to the treatment. To provide this care, my health care provider will rely on information I provide about my health, including genetic information such as family health history. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers. I agree that I have been able to share the information I would share in a face to face visit.

I provide consent to receive e-mails, calls and texts about your visit and health-care related information from or on behalf of Evivia, Eviviacare.com or any of its affiliates at the phone number or e-mail that I provided. Consent is not a condition of purchase and make be revoked at any time. Your carrier’s message and data rates apply.

Refund and Cancellation Policy

I agree to be charged a full price for the telemedicine visit. I agree that I am fully responsible for paying out-of-pocket the full charge via credit card, online payment or cash.

Services rendered are non-refundable and are not eligible for payment challenges. Telemedicine visit that has begun (e.x. an online visit form had been submitted) is considered to have been rendered. Rendered services include, but not limited to, telephone call, email, text, virtual or an in-person visit. I agree that I will not challenge such credit, debit, or financing card payments once the services are rendered. I agree that the credit card challenge is irrevocable.

Indemnification

I AGREE TO INDEMNIFY AND HOLD HARMLESS THE PROVIDER, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS OR DAMAGE, INCLUDING ANY AND ALL INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL OR EXEMPLARY DAMAGES, EXPENSES, LIABILITIES, CLAIMS, OR DEMANDS WHATSOEVER ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PROVIDER’S NEGLIGENCE.

The consents on this form will remain valid until I withdraw them in writing or until the law states they have expired. However, any actions already taken in reliance upon these consents will remain valid. (I cannot undo actions that were taken while my consent was valid.)

NOTE: Records are not automatically sent to my primary care physician (unless required by state law). I may request that my records be forwarded to my primary care physician.

By selecting “I AGREE to Terms of Use, Privacy Policy and Telehealth Consent” I am electronically signing this form and I certify:

That I have read the informed consent and Telehealth services agreement or had the agreement read and/or had it explained to me
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
I acknowledge that I am located in the State of Florida at the time I start this visit
I am at least 18 years of age
I am responsible for paying out-of-pocket the full charge for the online visit via credit card or online payment.
I accept the Terms of Service, Informed Consent for Telehealth Services, and I consent to and authorize the health care provider to use telehealth in my care, to assess and recommend treatment if necessary.

INFORMED CONSENT FOR COVID-19 DIAGNOSTIC TESTING

Authorizations and Consent for COVID-19 Diagnostic Testing:

I voluntarily consent and authorize Evivia LLC, its officers, employees, representatives, agents, third parties and/or independent contractors to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by a healthcare provider through a nasopharyngeal swab, nasal swab, oral swab, saliva sample, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and, as with any medical test, there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider.

I understand that I am not creating a patient relationship with Evivia LLC, its affiliates, employees, directors, representatives, agents, or independent contractors by participating in testing. I understand that Evivia LLC, its officers, employees, representatives, agents and/or independent contractors are not acting as my medical provider. I understand that testing does not replace treatment by my medical provider.

I acknowledge that a positive test result is an indication that I must start or continue to self-isolate in an effort to avoid infecting others.

I agree that I am fully responsible for paying out-of-pocket the full charge for COVID-19 testing via credit card, online payment or cash.

Services rendered are non-refundable and are not eligible for payment challenges.
I agree that I will not challenge such credit, debit, or financing card payments once the services are provided. I agree that the credit card challenge is irrevocable.

Patient Rights and Privacy Practices.

a) I understand that my sample(s) might be sent directly and anonymously to a third party independent lab for testing, processing and or analysis

b) Disclosure to Government Authorities: I acknowledge and agree my test results and associated information to be disclosed to appropriate county, state, or any other governmental and regulatory entities as may be permitted by law.

c) Disclosure to Credit Card, Debit Card, banks, or third party financing institutions: I understand that it may become necessary to release my protected health information to financial parties, credit card entities, banks, and financing companies, to facilitate my payment or to communicate with financial parties.

No-Show, Late, Refund and Cancellation Policy

I agree to be charged a full price for the visit. I agree that I am fully responsible for paying out-of-pocket the full charge for COVID-19 testing via credit card, online payment or cash.

Services rendered are non-refundable and are not eligible for payment challenges. I agree that I will not challenge such credit, debit, or financing card payments once the services are provided. I agree that the credit card challenge is irrevocable.

I agree that there will be no refund if I cancel and/or reschedule my appointment with less than 24 hour written notice to practice. I agree that a cancellation fee of $25 will be applied in case I want to cancel my appointment.

I agree that there will be no refund if I do not show up for my appointment “A no show.” A no-show is when a client misses the scheduled appointment without cancelling.

I agree and understand that my appointment may be rescheduled, if available, in the event I arrive late for my appointment “Late Arrival.” Late Arrival shall mean arriving at the clinic 15 minutes after the scheduled appointment time. I agree that there will be no refund in the event I arrive late for my appointment and no other appointments are available.

I will email info@eviviacare.com as soon as I know I am not able to make the appointment. I understand that the only way to cancel and/or reschedule the appointment is via providing a written notice to cancel to email info@eviviacare.com.

IDEMNIFICATION

TO THE FULLEST EXTENT PERMITTED BY LAW, I HEREBY RELEASE, DISCHARGE AND HOLD HARMLESS, EVIVIA LLC, INCLUDING, WITHOUT LIMITATION, ANY OF ITS AFFILIATES, MEMBERS, RESPECTIVE OFFICERS, DIRECTORS, EMPLOYEES, REPRESENTATIVES, INDEPENDENT CONTRACTORS, LAWYERS, STAFF, VOLUNTEERS, HEIRS AND AGENTS AGAINST ANY AND ALL CLAIMS, SUITS, OR ACTIONS OF ANY KIND WHATSOEVER FOR LIABILITY, DAMAGES, COMPENSATION OF WHATEVER KIND OR NATURE, OR OTHERWISE BROUGHT BY ME OR ANYONE ON MY BEHALF, INCLUDING ATTORNEY’S FEES AND ANY RELATED COSTS, IF LITIGATION ARISES PURSUANT TO ANY CLAIMS MADE BY ME OR BY ANYONE ELSE ACTING ON MY BEHALF ARISING OUT OF OR IN CONNECTION WITH ANY ACT OR OMISSION RELATING TO MY COVID-19 DIAGNOSTIC TEST OR THE DISCLOSURE OF MY COVID-19 TEST RESULTS.

By selecting the “I AGREE” acknowledgement to the Terms of Use, Privacy Policy and Informed Consent to COVID-19 Diagnostic Testing during the registration, request, and submission process for COVID-19 Diagnostic Testing at Evivia LLC, I acknowledge and agree that I have read, understand, and agreed to the statements contained within Terms of Use, Privacy Policy and Informed Consent to COVID-19 Diagnostic Testing. I have been informed about the purpose of the COVID-19 diagnostic test, procedures to be performed, potential risks and benefits, and associated costs. I have been provided an opportunity to ask questions before proceeding with a COVID-19 diagnostic test, and I understand that if I do not wish to continue with the collection, testing, or analysis of a COVID-19 diagnostic test, I may decline to receive continued services.I agree that I have been able to share the information I would share in a face to face visit. COVID-19 Testing Results are typically available within hours, on the same day, or in 24-48 hours, but may take longer due to an increased testing demand and/or the current surge in COVID-19 cases.

I have read the contents of the Terms of Use, Privacy Policy and Informed Consent to COVID-19 Diagnostic Testing in its entirety and voluntarily consent to undergo diagnostic testing for COVID-19.