Endocrine and Diabetes Associates, LLC

I acknowledge the following:

• I am a current patient at Endocrine and Diabetes Associates, LLC.
• I have scheduled this appointment in advance with my knowledge that this is a virtual visit.
• This virtual visit is not an emergency medical service. If I have an emergency I am aware that I will need to call 911 immediately to receive emergency medical care.
• I understand Doxy.me is the secure electronic communication platform used as a means to provide medical care to me by my provider and that once I connect to Doxy.me, I automatically agree to the service.
• I verify that I am in Maryland at the time of the virtual visit.

As a patient you have the right to your health and health information. You have the right to be informed of your medical condition.
I acknowledge:

• The purpose of the virtual visit is to seek medical evaluation, treatment, and care that will be provided by my physician.
• Information that I provide to my physician will be used to diagnose and treat my medical condition.
• During the virtual visit, my provider may ask for my medical records which may include current medications, images, lab results, data from my medical devices such as the insulin pump or continuous glucose monitor or glucometer to help guide treatment recommendations.
• This information will be asked through synchronous audio-video communication using the secure and private Doxy.me electronic platform using my computer or phone.
• I understand that if there is a disruption, disconnection, or poor quality of communication as determined by myself and/or my provider, that the virtual visit may end by either myself or by my provider. If my medical condition was not fully made known to my provider, I will need to provide that updated medical information to my provider either through a different virtual visit or an in person office visit.

Financial Responsibility:

• You are responsible for any co-payment, co-insurance, deductible, fees, or any out of pocket cost.
• This will be charged by the practice either before or after the virtual visit.
• If you do not have insurance, you will be directly responsible for the charges of the virtual visit.
• You verify that the insurance information on file is current or you have notified the office of any changes and have notified the office of any address change.

Benefits of virtual visits:

• You are able to have a secure and private virtual visit appointment from the comfort of your own space with your provider, virtually, and without the need to travel.
• You can still have access to medical care in real time.
• Less risk of acquiring other illness.
• Convenient and saves travel time

Potential risks associated with virtual visits:

• A virtual visit will not include a direct physical examination which otherwise may assist in the medical evaluation.
• A virtual visit will not include testing of your blood pressure or heart rate or weight/height, and you would need to provide that information if you want that included in you medical assessment.
• You may still need to come in for an office visit for further evaluation of your medical condition if the need is determined by your provider.
• The audio or video connection may be suboptimal either requiring you to reschedule to a different virtual visit or you may need to make an office visit.
• All of your medical information or records may not be transmitted readily or in a timely manner during a virtual visit and this may delay medical treatment or evaluation.
• Sometimes security protocols may fail with electronic communication systems which can make your personal medical information vulnerable to breach of privacy.

You acknowledge and agree to the following:

• The same privacy laws apply to virtual visits as they do in case of in person visits.
• Your virtual visit will be held up to the same standard of privacy of health information and confidentiality as an in person office visit.
• You can withdraw consent of the virtual visit at anytime without the risk of losing further medical care by your provider or the risk of not being able to schedule future appointments with your provider.
• If you are not comfortable with the virtual visit option, you may ask your provider alternative methods of visits to receive medical care.
• You may request an in office visit.
• You may be asked by your provider to be seen in person in order to better serve your medical care as determined by your provider.
• Sometimes electronic communication platforms may result in poor connection and you may need to reschedule your appointment or the visit may convert into a telephone visit if your insurer provides that service and if your provider determines that as appropriate.
• You have had the opportunity to ask questions regarding virtual visits.