Thank you for choosing us for your telehealth care. We want you to understand your rights and responsibilities while receiving care from us.
If you have any questions about this form, please ask your Provider.
Consent for Treatment:
- I consent to medical care performed by my physician and all other associated healthcare providers (i.e., Nurse Practitioners, Physician Assistants, etc.) at Circle Medical (the “Providers”).
- This care includes examinations, diagnostic testing, treatment, and other health care services deemed medically necessary in the Providers’ professional judgment.
- I understand that the practice of medicine is not an exact science and that diagnosis and treatment may cause injury or even death.
- I understand that I have the option to refuse the delivery of healthcare services at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any benefits to which I would otherwise be entitled. If I am pregnant, this consent also applies to my fetus.
- I understand that by signing this consent that Circle Medical may obtain and send copies of my medical records to/from another provider, Health Information Exchange (HIE), or health plan for treatment, payment, or healthcare operations.
- I understand that Circle Medical adheres to state and federal privacy laws. As such, sensitive results, such as HIV status or psychotherapy notes, may be protected by state and federal privacy laws, and if so they will only be released by Circle Medical to outside parties with my permission, or as is otherwise required by a court of law.
Consent for Telehealth Services:
Telehealth involves two-way synchronous audio and visual communication. It can also include asynchronous transmission of video, photographs, and/or details of my medical record such as x-rays and test results (collectively, “Data”). All Data is sent by secure electronic means to the Providers to facilitate the medical service being performed. I understand that:
- I will be informed of any other people who are present at either end of the telehealth encounter, and have the right to exclude anyone from either location.
- All confidentiality protections required by law or regulation will apply to my care.
- I have the right to refuse or stop participation in telehealth services at any time and request alternate services such as an in-person appointment. However, I understand that equivalent in-person services might not be available at the same location or time as telehealth services.
- If I do not want to receive health care services by telehealth, it will not affect my right to future care or treatment, or any insurance/ program benefits to which I would otherwise be entitled.
- If an emergency occurs during a telehealth encounter, emergency services will be contacted. The Provider may call 911 or may instruct me to do so. I should stay on the video connection (if applicable) until help arrives.
Payment Agreement/ Assignment of Benefits
I agree to be responsible for any co-payments, deductibles, or other charges from
the Providers and their providers that are not covered or paid by insurance or other third party payors–except as prohibited by any state or federal law, or any agreement between my insurance company and the Providers and Circle Medical.
I authorize the Providers and Circle Medical to file any claims for payment of any portion of the patient bills, and assign all rights and benefits payable for health care services to the provider or organization furnishing the services.
I agree, subject to state and federal law, to pay all costs, attorney fees, expenses, delinquent charges, and interest in the event the Providers and/or Circle Medical have to take action to collect the same because of my failure to pay all incurred charges in full.
- It is my responsibility to know what providers and telehealth services are covered under my insurance plan.
- I understand that I may be billed and agree to pay all bills submitted by the Providers, Circle Medicine, and/or other providers involved with the provision of telehealth services.
- If I think the information in my medical or billing record is incorrect, it is my responsibility to request a change, or amendment, to my record.
