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Informed consent for virtual care services

Introduction

I understand that Virtual Care Services (“Virtual Care”) provided by Village Medical allows a provider to see and communicate with me in real time even though he or she is physically located at another site. Virtual Care involves the use of interactive audio, video, or other electronic media. Virtual Care services will be delivered either by a Village Medical health professional, licensed, certified, or otherwise entitled to practice in this state or a Village Medical health professional acting under the delegation and supervision of a Village Medical physician (a “Village Medical Provider”).

Benefits and risks

Virtual Care visits offer benefits such as convenience and timely health care services. However, as with any health care service, there are potential risks associated with the use of Virtual Care including, but not limited to:

  1. In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to
    allow for appropriate medical decision making by the Village Medical Providers;
  2. Delays in health care services provided via Virtual Care could occur due to deficiencies or failures of the equipment;
  3. In very rare instances, security and encryption protocols could fail, causing a breach of privacy of personal medical information; and
  4. In rare cases, Village Medical Providers may not have access to complete medical records which may result in advice, recommendations, and/or decisions based on factors not within their control.

Consent for treatment

I voluntarily consent to health care services provided to me via Virtual Care. I understand that Village Medical Providers:

  1. May practice in a different location than where I go for my primary care visits,
  2. May not have the opportunity to perform an in-person physical examination and may be limited in their ability to fully diagnose a condition or disease, and
  3. Rely on information provided by me that is complete and accurate to the best of my ability.

I understand that parts of my care and treatment which require physical tests or examinations may be conducted by providers and their staff at my physical location under the direction of the Virtual Care Provider. I accept responsibility for following the Village Medical Provider treatment recommendations.

If the Village Medical Provider determines that the Virtual Care services do not adequately address my medical needs or if there is a disruption in the Virtual Care session, an in-person medical evaluation may be necessary. IF I EXPERIENCE AN URGENT MATTER AFTER OR DURING A VIRTUAL CARE SESSION, I SHOULD ALERT MY TREATING PHYSICIAN AND, IN THE CASE OF EMERGENCIES DIAL 911, OR GO TO THE NEAREST HOSPITAL EMERGENCY DEPARTMENT.

How we may use and disclose your health information

The laws that protect privacy and the confidentiality of medical information also apply to Virtual Care. Village Medical will only use and disclose your health information in accordance with our Notice of Privacy Practices (“Notice”). Our Notice also explains how you may submit a request to review and receive a copy of your health information. You have the right to a paper copy of this Notice. In addition, a copy of this Notice may also be obtained at our website, https://www.villagemedical.com.

Billing

I understand that an insurance claim will not be submitted to my insurer and that I am financially responsible for my Virtual Care visit.

E-communication

As a component of my care, I understand and agree that Village Medical may contact me using automated calls, e-mails, and text messages sent to my mobile device. These communications include reminders of my scheduled appointments, to share information regarding new services provided by Village Medical, and other communications related to my care. I understand that that there are risks associated with electronic communication. I acknowledge that Village Medical will ensure that the electronic communication utilized will be encrypted and secure to minimize those risks associated with my privacy and confidential information. If I no longer wish to receive electronic communications from Village Medical, I must opt-out by e-mailing contact@villagemedical.com. Village Medical will make every effort to use my preferred method of contact indicated below.

Withdraw consent

I understand that I have the right to withdraw my consent to the use of Virtual Care at any time, without affecting my right to future care or treatment. I may revoke my consent in person or by phone at any time by contacting Village Medical or the clinic I visited. Village Medical may provide Virtual Care services without the need for me to sign another consent form so long as I have not withdrawn my consent and I have previously received Virtual Care services from the Village Medical provider. □ I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.□ I acknowledge that I have reviewed and consent to the physicians’ privacy practices.

Grievances

While we hope every patient’s visit goes smoothly, it is important that we are notified of patient concerns so we can take the appropriate steps to address them. Please contact us by phone ((224) 325-1209) or e-mail (risk-management@villagemd.com) if you have concerns.

Please save a copy of this consent and the Joint Notice of Privacy Practices for your records.