HYBRID MEDICAL SOLUTION Consent for Non-Face To-Face“Virtual” Visits

Patient Name: First Name Last Name Date of Birth: Date

Todays Date: Date Time: Type a label AM /PM

Name Signature Date Date

I, First Name Last Name hereby voluntarily consent to receive “virtual” care.

Examples of the virtual services offered at Hybrid Medical Solution include:

Virtual check-ins: You and your treating provider may have a brief phone call to determine whether or not an in person visit or other appropriate treatment is needed.

E-Visits: you may communicate with your treating provider through our patient portal (Patient Fusion) or secure email.

I understand that this consent form will be valid and remain in effect as long as I receive medical care at hybrid medical solution.

“Virtual Visits” mean that you may be evaluated and treated by a healthcare provider from a distant location via electronic communication. Since this may be different than the type of consultation with which you are familiar, it is important you understand and agree to the following statements:

•      Your treating provider will be at a different location from you. Additional medical or registration personnel may also be present in the room with the provider.  Initial Here
•      I understand that my voice and image may be recorded in order to assist in my treatment and I consent to any such audio and video recording.   Initial Here
•      I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination. I understand there are alternatives and limitations to this type of care. I understand that my health care provider or I can discontinue the telemedicine consultation/visit if it is felt that the videoconferencing connections are not adequate for my situation.   Initial Here
•      I understand that I may be disconnected before all my medical problems are known or treated and it is my responsibility to make such conditions or symptoms known to the medical personnel as well as to make arrangements for follow-up care.   Initial Here
•      I understand that standard deductible and coinsurance amounts applied to these “Virtual Visits” and I consent to virtual treatment.   Type a label
•      I understand that standard deductible and coinsurance amounts applied to these “Virtual Visits” and I consent to virtual treatment.   Initial Here

This form has been explained to me and I fully understand this consent for non-face-to-face “Virtual Visits” and agree to its contents.

Signature of patient or person authorized to consent for patient:

Signature

Date