INFORMED CONSENT FOR THE USE OF ELECTRONIC MEDIA COMMUNICATION FOR MEDICAL DIAGNOSIS AND SERVICES
Last updated: March 9, 2016
Telemedicine: Telemedicine is the use of electronic/internet/data transmissions to treat the needs of a client. This means the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.
Medical Provider: Medical provider means the hospital, doctor’s office, clinic, outpatient facility, diagnostic testing facility, pharmacy, emergency transportation service (ambulance services) or other healthcare entity that the Client is utilizing or visiting to receive medical treatment, consultation, examination, testing, diagnosis or other healthcare services.
Healthcare Practitioner: Healthcare practitioner means the doctor, nurse, aide, medical assistant, medical technician, paramedic, pharmacist or person rendering or facilitating healthcare services for a Medical Provider or for themselves.
Healthcare Service: Healthcare services shall means those services that are received by or rendered to a Client from a Medical Provide and/or Health Practitioner for the purposes of medical treatment, diagnosis, examination, testing, consultation, claims, insurance, billing, payment and/or education.
HIPAA: Health Insurance Portability and Accountability Act is a law that ensures the protection of private patient information in the rendering of healthcare services to a patient by a Medical Provider or Healthcare Practitioner.
Protected Health Information: Healthcare, medical and personal information concerning a patient that is protected from disclosure and dissemination to third parties pursuant to federal and state law.
By agreeing to this consent form, YOU, the Client, agree to use Healthchat to communicate electronically with a Medical Provider and/or Healthcare Practitioner in order to receive healthcare services and health-related communications through Healthchat’s electronic communication mediums or systems. YOU, the Client, further authorized the release and/or dissemination of your Protected Health Information (“PHI”), including but not limited to records relating to mental healthcare, communicable disease, HIV, AIDS or the treatment of alcohol or drug abuse, to third parties if YOU, the Client, utilize Healthchat’s electronic communication mediums or systems to communicate this information with third parties. Healthchat will use its best efforts to protect YOUR PHI and abide by HIPAA/PHI standards as well as applicable federal and state law. YOU, the Client, further understand that a revocation is not effective to the extent a Healthchat or a third party has acted in reliance on YOUR authorization. YOU, the Client, further understand that YOUR treatment, payment, enrollment, or eligibility for benefits with a Medical Provider or Healthcare Practitioner will not be conditioned on whether or not YOU consent to this informed consent form.
You, the Client, also acknowledge that there are logistical and privacy issues that may or may not be compromised in the use of such electronic communication medium. Please read the following section to show your understanding of your rights under this disclosure:
(1) YOU, “the Client”, retain the option and right to withhold or revoke your consent to using Healthchat as the electronic communication medium or system for healthcare services and/or health-related communications at any time once initiated by yourself with a Medical Provider, or Healthcare Practitioner.
(2) The risks involved with Telemedicine include the potential release of private information due to the complexities and abnormalities involved with the Viruses, Trojans, and other involuntary intrusions have the ability to grab and release information you may desire to keep private. Furthermore, there is the risk of being overhead by anyone near YOU if YOU do not place yourself in a private area and open to other’s intrusion. Healthchat takes proper precautions and security measures in order to protect your PHI/HIPAA information such as encryption and password protections.
The advantages of Telemedicine include the benefit of continuity of care in the absence of your selected Medical Provider or Healthcare Practitioner as well as the ability to be treated from any location at any time. It is YOUR responsibility to create an environment on YOUR end of the Telemedicine transmission that is not subject to unexpected or unauthorized intrusion of your PHI.
(3) All existing confidentiality protections apply to YOU, the Client as it relates to YOUR communication with a Medical Provider and/or Healthcare Practitioner.
(4) All existing laws regarding client access to electronic medical information as well as copies of YOUR medical records apply as it relates to communications with a Medical Provider and Healthcare Practitioner
(5) Dissemination of any identifiable images or information from the telemedicine interaction with YOUR Medical Provider and/or Healthcare shall not occur without YOUR consent, however, Healthchat is a simply a electronic communication medium or system used by Healthcare Practitioners, Medical Provides and Clients and does not disseminate information on its own accord to other persons or entities. By consenting to this informed consent form, YOU, the Client have consented to said dissemination of YOUR images and information through Healthchat.
(6) Healthchat is NOT a Medical Provider or Healthcare Practitioner, does not hold itself out to be either one of these entities, and does not engage in the practice of medicine or any other healthcare-related service. Healthchat is an electronic communication medium or system used to provide Telemedicine services to the public.
(7) Healthchat may disclose YOUR PHI in its possession, if any, to other third parties to comply with applicable state and federal law; in accordance with in an administrative or judicial proceeding; or pursuant to court order, without prior written consent from YOU, the Client.
(8) Any inspection, restriction, copying, accounting, or amending of YOUR PHI must be done through YOUR Medical Provider or Healthcare Practitioner.
(9) This informed consent form acknowledged and agreed to by YOU shall become part of Healthchat’s records.
ACKNOWLEDGMENT OF THE RISKS AND BENEFITS OF THE USE OF TELEMEDICINE
I acknowledge that I have fully reviewed and read this informed consent form concerning Telemedicine services and the use of Healthchat and have chosen Healthchat as the method of communication to communicate with a Medical Provider or Healthcare Practitioner. I understand that the electronic communication medium used by Healthchat will allow for video and audio conference participation as well as texting and messaging services.
I understand that there are no universal protocols or protective standards in the use of Telemedicine and I will hold Healthchat harmless and free from liability in the event I use this method of communication to engage a Medical Provider or Healthcare Practitioner in this manner. I also understand that Healthchat does not represent nor is responsible for ensuring that the a Medical Provider or Healthcare Practitioner is in compliance with Telemedicine or telehealth laws in my state, province or country, I further understand that there are both risks and benefits as mentioned within this consent form as well as others that I may not fully be aware of that can occur with or without our knowledge.
I agree that by electronically consenting to this consent form that Healthchat has informed me of the risks and benefits regarding the use of Telemedicine as a means of facilitating my medical treatment, consultation and/or examination, and that officially consent to using Healthchat knowing this information. YOU, the Client, should not consent to this consent form and use Healthchat if YOU, the Client, do not agree with any of the information, terms and/or conditions set forth in this informed consent form.