CONSENT TO TREAT AND TELEHEALTH CONSENT

This consent provides us with your permission to perform reasonable and necessary medical examinations and treatment. It also permits us to provide these services as telehealth services.  By signing below, you are indicating that you understand that this consent is continuing in nature, even after a specific diagnosis has been made and treatment recommended. You always have the right to ask additional questions, to discontinue services or decline services.

TELEHEALTH SERVICES

All telehealth services will be provided in a HIPAA compliant manner. For all online telehealth services, service will be from a private office space where your privacy is ensured. Patients can connect to telehealth services using any approved digital device (computer, smart phone, etc.). An internet connection is necessary in order to participate in most telehealth services. It is the responsibility of the patient to ensure your privacy on your end when participating in telehealth services. All other procedures regarding informed consent for treatment, privacy practices, and rights & responsibilities will be followed as per in person services.

Consent for Treatment

I voluntarily consent and agree to Advanced Cardiac and Vascular Centers to perform reasonable and necessary medical examination, testing and treatment for the condition that has brought me to seek care at this practice. I understand some services may be provided as telehealth services. I understand telehealth services involve the use of audio, video or other electronic communication technologies. I understand it is my responsibility to find a secure and private location for the telehealth services. I understand that there are potential risks related to use of telehealth such increased risk for breach of confidentiality if I am not in a private place during the session. I understand that there may be limits to treatment modalities utilized with use of telehealth vs in person treatment options. I further understand technical difficulties may arise that could affect the quality or time of the telehealth session; I will not hold the provider responsible for any technology related problems.

I understand that I may withdraw my consent at any time I choose to do so either in writing or verbally.

This form has been fully explained to me, and I certify that I understand and agree to its contents and the purpose thereof. I agree to be contacted by telephone, text message and email. I also certify that I am legally able to provide consent for the person named above.