DMS Telehealth Consent for DBQ Evaluation

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Purpose of this Telehealth Encounter* This field is required.Please check all boxes to acknowledge understanding and agreement.
You are requesting a telehealth medical evaluation for the purpose of completing a Disability Benefits Questionnaire (DBQ) or similar medical documentation related to a federal or veterans' disability claim.
You understand that this encounter is limited to medical evaluation and documentation and is not intended to establish ongoing medical care.
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Nature of Telehealth* This field is required.Please check all boxes to acknowledge understanding and agreement.
Telehealth involves the use of secure audio and/or video communication technology to conduct a medical evaluation remotely.
This telehealth visit may include review of medical history and records you provided.
This telehealth visit may include discussion of symptoms, functional limitations, and medical history .
This telehealth visit may include clarifying questions necessary to complete the DBQ accurately.
No physical, hands-on examination will be performed.
You must be physically located in Washington state on the day of the DBQ evaluation, in accordance with state medical regulations.
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Scope and Limitations of the Telehealth DBQ Evaluation* This field is required.Please check all boxes to acknowledge understanding and agreement.
This telehealth visit is being conducted solely for the purpose of completing a DBQ or medical opinion.
This evaluation does not establish a physician-patient relationship.
No diagnosis, treatment plan, prescriptions, or medical management will be provided.
The evaluating physician's role is limited to offering an independent medical opinion based on your reported history, the available medical records, and medical expertise and professional judgement.
Completion of the DBQ does not guarantee approval of a disability claim or benefits. Final adjudication rests with the Department of Veterans Affairs.
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Risks and Limitations of Telehealth* This field is required.Please check all boxes to acknowledge understanding and agreement.
An inherent limitation of telehealth evaluations includes the inability to perform a hands-on physical examination.
An inherent limitation of telehealth evaluations includes potential technical issues (e.g. connectivity problems).
An inherent limitation of telehealth evaluations includes reliance on the accuracy and completeness of information you provide.
You agree to promptly notify the physician if you experience technical difficulties during the visit.
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Privacy and Confidentiality* This field is required.Please check all boxes to acknowledge understanding and agreement.
Reasonable efforts are made to ensure the privacy and security of telehealth communications. Despite safeguards, there is a small risk of unauthorized access or technical failure.
You agree to participate from a private location where your information cannot be overheard.
Your medical information will be handled in accordance with applicable privacy laws.
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Emergency and Urgent Medical Care* This field is required.Please check all boxes to acknowledge understanding and agreement.
Telehealth DBQ evaluations are not appropriate for emergencies.
If you are experiencing a medical emergency, you should call 911 or seek immediate in-person medical care.
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Voluntary Participation* This field is required.Please check all boxes to acknowledge understanding and agreement.
Participation in this telehealth DBQ evaluation is voluntary.
You may decline this telehealth DBQ evaluation at any time prior to or during the encounter.
You may withdraw consent for this telehealth DBQ evaluation at any time prior to or during the encounter.
You acknowledge that declining or withdrawing consent will prevent completion of the DBQ, since an examination is required by the VA (page 1 of the VA DBQ form) in order to complete the DBQ.
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Consent and Acknowledgement* This field is required.Please check all boxes to acknowledge understanding and agreement.
You requested that our physician complete your VA Disability Benefits Questionnaire, for which the VA requires an examination.
You have read and understand this telehealth consent form.
You consent to participate in a telehealth medical evaluation for DBQ purposes.
You understand the scope and limitations of this telehealth DBQ evaluation.
You confirm that you will be physically located in the state of Washington at the time of the telehealth appointment. You understand that providing false information may result in cancellation of service without refund.
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Please Sign to Submit this Form* This field is required.
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Please verify that you are human* This field is required.
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