MICARE PATH VIRTUAL HEALTHCARE SERVICES CONSENT FORM
Thank you for choosing us to provide you virtual healthcare services in conjunction with our technology and service partner, MiCare Path! You are receiving this form because you have indicated that you are interested in receiving virtual healthcare services, such as remote patient monitoring, remote therapeutic monitoring, and other related healthcare services that can be provide through a HIPAA compliant software platform.
Virtual healthcare services are healthcare services that are provided through electronic communication technologies with audio and video capabilities. Virtual healthcare services allow you to communicate with your clinical care team, provide real time information regarding your clinical conditions, concerns, signs, and symptoms, and allows them to monitor, respond to, and address certain clinical conditions, sometimes, without the need for an in-person office visit. Virtual healthcare services also support patient engagement and education on being a more informed advocate for one’s personal health and well-being.
As with any medical treatment, there are potential risks associated with the use of virtual healthcare services. We believe that the likelihood of these risks materializing is low.
These risks may include, without limitation, the following:
By signing below, you acknowledge that you understand and agree to the following:
This Virtual Healthcare Services Consent Form is valid until you withdraw it or until you no longer receive treatment from your prescriber.
I HAVE READ AND UNDERSTAND THE INFORMATION PROVIDED ABOVE, AND UNDERSTAND THE RISKS, BENEFITS, AND ALTERNATIVES OF VIRTUAL HEALTHCARE SERVICES, AND I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN THESE SERVICES UNDER THE TERMS DESCRIBED. I UNDERSTAND THAT BY CLICKING “I AGREE”/SIGNING BELOW, I AM CONSENTING TO RECEIVE VIRTUAL HEALTHCARE SERVICES. I UNDERSTAND THAT THE SCOPE OF MY CARE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PROVIDER WHO IS TREATING ME, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR OUTCOME. MY HEALTHCARE PROVIDER WILL DETERMINE WHETHER OR NOT THE CONDITION(S) BEING DIAGNOSED AND/OR TREATED ARE APPROPRIATE FOR VIRTUAL HEALTHCARE SERVICES. BY SIGNING BELOW, I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO ASK ANY QUESTIONS I HAVE REGARDING THE SERVICES, THAT THE RISKS, BENEFITS, AND ALTERNATIVES HAVE BEEN DISCUSSED WITH ME, THAT I HAVE HAD ALL MY QUESTIONS ASKED AND ANSWERED TO MY COMPLETE SATISFACTION, AND I AM HEREBY GIVING MY INFORMED CONSENT TO RECEIVE VIRTUAL HEALTHCARE SERVICES.
Patient Name – Print Date
Patient/Legal Guardian Signature Date