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.  

What are Virtual Healthcare Services

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.

What are the Possible Risks to Using Virtual Healthcare Services?

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:

• Delays in medical consultation or treatment may occur due to deficiencies or failures of the equipment, which may include poor video and data quality.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• Lack of access to complete medical records may result in a lack of full comprehensive care management recommendations.
• As with any internet communication, virtual healthcare services carries a risk of service interruption. 

Your Rights and Acknowledgements:

By signing below, you acknowledge that you understand and agree to the following: 

• You agree to receive virtual healthcare services via our healthcare software communications platform. Our affiliates include other contracted companies and entities involved in our delivery of care to you.
• You have the same privacy rights via virtual healthcare services that you would have during an in-person visit. 
• Virtual healthcare services may involve electronic communication of your personal medical information to medical and clinical practitioners who may be located in other areas, including out of state.
• You understand that you may expect the anticipated benefits from the use of virtual healthcare services, but that no results can be guaranteed or assured.
• You understand that your healthcare information will be included in your medical record. This information will have the same applicable restrictions on dissemination without your consent as other medical information, in accordance with the Health Information Portability and Accountability Act (“HIPAA”). 
• Except to the extent already relied upon, you understand you may withdraw your consent at any time.
• You understand that your healthcare information may be shared with other individuals for treatment, payment and healthcare operations purposes, including billing providers for processing payments.
• You further understand that your healthcare information may be shared in the following circumstances in accordance with HIPAA:
  1. When a valid court order is issued for medical records.
  2. Reporting suspected abuse, neglect, or domestic violence.
  3. Preventing or reducing a serious threat to anyone’s health or safety.

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