Virtual Urgent Care Patient Registration Form

If you selected yes to any of the preceeding questions, please call 911 or go to your nearest hospital emergency room immedicately. 

This consent is for all telehealth services provided to me by H.E.A.L. Mississippi. 

Telehealth is the use of the Internet to provide remote health care for patients. Such care may come from doctors, nurses, mental health providers, and professional health educators.

Specifically, a health care professional will be communicating with me remotely via the Internet using doxy.me web-based audio-video software {referred to in this form as Telehealth Appointment). Doxy.me only hosts the software and does not provide medical advice or information.

This Telehealth Appointment may be for diagnosis. continuity of care, treatment. testing, or medical consultation deemed necessary by my Healthcare Provider or me.

I understand that during a Telehealth Appointment: 

•   details of my medical history and personal health information may be discussed with me and/or other health professionals;

•   audio,video, or photo recordings containing medical details may be transmitted via secure channels and those details may become part of my permanent medical record;

•   all confidentiality protections granted to me by various state and federal laws also apply to my care during this appointment;

•   industry-standard network and software security protocols are in place that protect the privacy of the communication and safeguard my transmitted information against eavesdropping and corruption;

•    there may be security and privacy risks associated with Internet-based communications;

•   there are benefits and limitations when compared to a traditional in-person visit due to the fact that I will not be in the same room as my healthcare provider;

•    either my Healthcare Provider or I can discontinue the Telehealth Appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic decision-making or for providing the care I desire;

•   in addition to my Healthcare Provider named above, I will be informed of any other person(s) who may be present during the appointment and have the right to have them leave the viewing and listening area;

•   to maintain my privacy, I need to ensure that my viewing and listening area is limited to myself and any other person that has a need to participate during the virtual appointment;

•    due to the limitations of telehealth that are out of my control (such as an unreliable internet connection). I will call local authorities (9-1-1) to assist me with a medical emergency:

•   I have the right to omit or withhold specific details of my medical history/physical examination that are personally sensitive;

•   my Healthcare Provider may advise me to seek immediate treatment or determine that there is a medical emergency and, as such, local authorities may be given my personal details to assist me:

•   the communication is privileged and confidential, and I will not record the audio or video without first seeking the permission of my Healthcare Provider.

THEREFORE, BY CONSENTING TO THIS TELEHEALTH APPOINTMENT:

1. I desire to engage in remote audio-visual communication with my Healthcare Provider.

2. I understand the risks and benefits of usingInternet-based communications and that no results can be guaranteed.

3. I acknowledge that if the Healthcare Provider believes that remote communication is insufficient for treatment, consultation, or evaluation, then I will be offered alternate services or options.

4. I understand that I may be responsible for co-payments, deductibles, or other charges from my Healthcare Provider, and additional charges may occur for seNices related to this appointment.

5. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Healthcare Provider.

6. I have the ability to ask direct questions to my Healthcare Provider about this appointment, including details about the Healthcare Provider's privacy policy.

7.  If my questions are not answered to my satisfaction, I have the right to terminate the appointment.

8. I am at least 18 years of age.

 

Thank you for scheduling your visit with us and allow us to care for you! Here are some important steps to follow for to be prepared for your appointment: 

• Please have your ID present. 
• Please be prepared to show your insurance card if using your insurance.
• Please have your debit or credit card ready for self-pay or co-pay. 
• Please make sure you are in a place with secure and stable internet access.
• Please make sure you and in an area where your privacy can be protected.
• Please make sure the camera on your device is working properly. 
• Please access the link below at least 10-15 minutes prior to your appointment. https://HEALMississippi.doxy.me/healmississippi

Thank you and we look forward to serving your healthcare needs!

Here is the link to your appointment: 

https://HEALMississippi.doxy.me/healmississippi

This Notice of Privacy Practices is NOT authorization. This Notice of Privacy Practices describes how we, H.E.A.L. Mississippi, our business associates and their subcontractors, may use and disclose you protected health information (PHI) to carry out treatment, payment or healthcare operations and for other purposes permitted by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including information that may identify you and information that may relate to your past, present, and future health conditions and related healthcare services.

To review, please click here: https://healmississippi.com/hippa/

I hereby authorize H.E.A.L. Mississippi to charge my credit/debit card above for the agreed upon services.