I give my consent for the patient, named above, to receive medical care from the City of Medicine Volunteer Medical Corps (VMC) through telehealth and in-person care.
I consent to and authorize the physician(s), physician assistant(s), nurse practitioner(s), resident physician(s), healthcare student(s), and clinical staff to provide diagnostic procedures and medical treatment including, but not limited to minor procedures and routine services deemed necessary at the time of the office visit, to me or the patient named on this form. I understand that the practice of medicine is not considered exact science and acknowledge that no guarantees have been made to the patient named on this form.
Medical Education: I agree that care may be provided by student nurses, technicians, therapists, interns, residents, fellows and other providers, which are supervised by qualified faculty in accordance with organizational policies.
Photography and Other Recordings: I consent to photographs, audio and video recordings, digital or other images that may be recorded to document my care. I understand that these images may be used for case study and research. I understand that these images will be stored in a secure manner and will only be released for non-treatment reasons If I or my legal representative provide written authorization by me. I consent to having part of my care be provided by use of video equipment, without the physician being physically present in the exam room.
Data Use: To better understand how telehealth is working and to ensure we are meeting the needs of children, families, and staff, we will be tracking data on the telehealth services and its impact. More specifically, we are interested in understanding information such as: how many people are using telehealth services, for what reasons are people using telehealth, what is the result of the telehealth service (for example – did the student need to go to the hospital or home), how does telehealth affect absenteeism and academics in student and staff who use it, has telehealth been able to connect students and staff to other services, how is telehealth helpful to parents, etc.
The data will be shared in an anonymous way with the Community Schools evaluation partner at the Duke Clinical Research Institute through a secure, electronic portal. Duke Clinical Research Institute will not have access to names of students, families, or staff. The Duke Clinical Institute will use the information to create summaries and provide overall feedback about progress, challenges, and successes to the telehealth service providers, school, district, state liaisons, and funders. We are also hopeful that the information can be used to support expanding telehealth services in the future.
Authorization for Healthcare-Related Calls, Texts and E-mails: I, the undersigned, hereby authorize and consent to employees, agents, representatives, affiliates, business associates, and/or designees contacting me using prerecorded/artificial voice messages and/or automatic dialing services at any telephone number (including a wireless telephone) that I provide. This consent and authorization will apply to text messages sent to the wireless numbers I provide and also to e-mails using any e-mail address that I provide. I understand that texting or emailing to the numbers and addresses I provide may not be secure. This consent and authorization will apply to the current visit and any future visits. This consent and authorization is valid until revoked by me, in writing, by certified mail sent to the following address:
COMVMC, 6409 Fayetteville Rd, Suite 120, #, Durham NC 27713
I have completed the Patient Demographic Form and authorize VMC to bill Medicaid or other insurance providers for these services. I assign payments of authorized benefits directly to VMC. I understand that I will not be charged for any of the services provided through the telehealth services program that are not covered by insurance.
I received a copy of the Health Care Centers in Schools “Notice of Privacy Practices”. I understand that VMC has the right to change this notice at any time. I may obtain a current copy by contacting the administrative office of VMC.
I understand that VMC programs may participate in one or more health information exchanges (HIEs), whereby the clinic may share my health information with other health care providers for treatment, payment, or health care operations purposes.
I understand that there will not be payment required for any of the services provided through VMC’s telehealth and school-based services. I also understand that VMC or the medical provider will bill Medicaid or other insurance providers for these services. I authorize/assign payments of authorized benefits directly to VMC.