ICGMV GROUP REGISTRATION FORM

I, hereby consent to participate in group or individual Medical Visits. 

The staff explained to me the activities that occurred during the medical visit and provided me with the pertinent handouts.  I understand that a healthcare staff member or staff member will be available. I understand that my protected health information may be shared with the group by the leader to further my medical treatment. I understand that I will be hearing about the medical care and conditions of others in the group, and I have been assured that my protected health information will continue to remain confidential outside of the group medical visit sessions. I understand that my records are and will continue to be protected under applicable Federal and State Regulations., including but limited to the heath Insurance Portability and Accountability Act of 1996, Title 42 of the Code of Federal Regulations, the Health Information Technology for Economic and Clinical Health Act, and cannot be disclosed without my written consent unless otherwise provided for by law.

I understand that: 

I will be in the group/visit with a medical care provider or/and other patients with similar concerns. 

It is my right to withhold personal information that  I do not wish to share. 

It is my responsibly to respect the privacy of others. I will not share their personal information with anybody else. 

I may speak to a medical care provider alone is I have additional problems to discuss. 

I can withdraw at any time for any reason. 

Not participating will not affect my relationship with my provider or my ability to receive service with Kronos health. 

This consent is a supplement to the general consent for services. 

 

My signature confirms that I clearly understand the activities that occur during a Group/Individual Medical Visit and that I am willing to participate. 

I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to provide health  care services. to me via telemedicine.

 

I understand that telemedicine is being used for the treatment of my case.
 

I understand that the laws that protect the privacy and the confidentiality of medical information (HIPAA) also apply to telemedicine. I will not discuss the issues outside the forum with anyone, to respect to their privacy. 
 

I understand my insurance carrier will have access to my medical records for quality review/audit. 
 

I understand that i will be responsible for any copayments, coinsurances, and co-deductibles that may apply to me during this telemedicine visit. 
 

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my are at any time, without affecting my right to future care or treatment in the office or any future telemedicine visits. 
 

I may revoke my consent orally or in writing at any time by contacting Kronos Health/Integrated Center of Group Medical Visits at  978-655-6652.

I , grant Kronos Health and ICGMV the absolute rights and permission to use, reproduce, copy, exhibit or distribute the videotape, audio tape, photographs, or computer files (referred to hereafter as “Video”) in which I may be included for the sole purpose of promoting the services and programs provided by Kronos Health and ICGMV. 

I hereby release, discharge, and agree to hold harmless Kronos Health and ICGMV from any liability or injury that may occur while performing or appearing in the Video. 

I understand that Kronos Health and ICGMV have no financial commitment or obligation to me as a result of this agreement. I hereby give all clearances, copyright, and otherwise, for the use of my name, likeness, image, voice, appearance, and performance embodied in the Video.  

I understand that it is neither expected nor required that I participate in the Video, and I have the right to halt my participation at any point during filming. 

In the case of a minor, I hereby warrant that I am the legal guardian of the minor named below and have every right to contract for him/her in the above regard. I state further that I have read the above authorization, release, and agreement prior to its execution, and that I am familiar with the contents thereof. 

 

 

OR

 I decline to grant Kronos Health and ICGMV the absolute rights and permission to use, reproduce, copy, exhibit or distribute the videotape, audio tape, photographs, or computer files (referred to hereafter as “Video”) in which I may be included for the sole purpose of promoting the services and programs provided by Kronos Health and ICGMV.