“Virtual” or “telehealth” visits refer to being evaluated and treated by your health care provider via electronic communication while you and your treating provider are in different locations. Examples of the virtual services offered pursuant to this consent include:

• Virtual check-ins: brief phone call to determine whether an in-person visit or other appropriate treatment is necessary
• E-visits:  direct communication with provider through your secure patient portal
• Telehealth visits:  use of real-time interactive audio and video communication to conduct a visit while you and your treating provider are in different locations
• Phone Calls:  communication via a phone call as a means to deliver a service comparable to an in-office visit

I understand there may be limitations and/or special conditions relating to virtual or telehealth visits including:

1. There are potential risks associated with this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination.  I understand that my health care provider or I may discontinue the telemedicine consultation/visit if either party determines that the videoconferencing connections are not adequate for my situation.
2. I may be disconnected before all my medical problems are known or treated. It is my responsibility to make such conditions or symptoms known to the medical provider and to make arrangements for recommended follow-up care.
3. Standard deductible and coinsurance amounts apply to these “virtual” or “telehealth” visits and I consent to virtual treatment.