Informed Consent to Telehealth Services and Private MD Care Policies
This form describes Private MD Care’s Telehealth treatment and payment policies and includes:
- Your consent to receive medical treatment from Private MD Care (and your other rights and responsibilities);
- Your agreement to receive services using telehealth technology; and
- Your agreement to pay in full any charges that are your responsibility.
If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.
- By using the Private MD Care telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my Private MD Care provider and I will be able to see and speak with each other from remote locations.
- I understand and agree that:
- I will not be in the same location or room as my medical provider.
- My Private MD Care provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.
- Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my Private MD Care provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
- Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Private MD Care responsible for lost information due to technological failures.
- I further understand that my Private MD Care Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my Private MD Care provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
- I may discuss these risks and benefits with my Private MD Care provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by Private MD Care.
- I understand that the level of care provided by my Private MD Care provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.
- In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
- I consent to, understand and agree that:
- I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
- Private MD Care will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
- My Private MD Care provider will not prescribe opioids to me during a telehealth visit.
- I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Private MD Care’s standard policies regarding request and receipt of medical records and applicable law.
- The laws of the state in which I am located will apply to my receipt of telehealth services.
Private MD Care Notice of Privacy Practices (“Privacy Notice”)
Private MD Care will protect the privacy of my health information and will not use or disclose it except as permitted by law. Private MD Care’s privacy policies are more fully described in the Privacy Notice, which is available for review and download here: https://privatemdcare.com/privatemdcare-privacy-policy. By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to Private MD Care’s use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services.
I acknowledge, understand and agree that:
- I will pay at time of service.
- By providing my credit card information and receiving telehealth services, I (i) authorize Private MD Care to charge my credit card for any and all unpaid amounts that Private MD Care determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that Private MD Care may charge my credit card for such amounts at the end of my telehealth visit or at a later date.
- I will be billed for all unpaid balances deemed by Private MD Care to be my responsibility and agree to pay such amounts in full. Delinquent accounts may be turned over to a collection agency at which time I am responsible for a $40 collections charge and all associated legal fees in addition to the amount owed.
- Private MD Care reserves the right to deny non-emergency services if my account is delinquent.
I understand that I may access and print a copy of this Consent here: https://privatemdcare.com/informed-consent