Comprehensive Pain Solutions DBA Quave Clinic Telemedicine Secure Online Video Appointment Consent Form
Consent for Treatment: I consent to telehealth/telemedicine care performed by my physician and all other associated health care providers at Comprehensive Pain Solutions (DBA Quave Clinic). This includes examinations, diagnostic testing, treatment and other health care services deemed medically necessary in my Providers’ professional judgment. I also understand that I have the option to refuse the delivery of health care services by telehealth/telemedicine 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.
Consent for Telehealth/Telemedicine Services: Telehealth/Telemedicine involves 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 Provider 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/telemedicine encounter and have the right to exclude non-essential personnel 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/Telemedicine services at any time and request alternative services such as an in-person appointment. However, I understand that the equivalent in-person services might not be available at the same location as the Teleheath/Telemedicine services.
• This Telehealth visit is being made available to me during this time of national crisis in order to reduce community spread of COVID-19.
• If an emergency occurs during a telehealth/telemedicine encounter, 911 will be called and your Provider will stay on the video until help arrives.
Records and Release of Information: Transmitted Data may become part of my medical record. Data will not be transmitted to people outside of my health care team except as described below, and/or if I provide additional consent.
• I will have access to all of the information in my medical record resulting from the telehealth/telemedicine services that I would have for a similar in-person visit, as provided by federal and state law.
• The Provider may use or disclose my health information for treatment, continuity of care, payment, or internal operations, or when required by law or regulation in certain unique situations.
• All releases of information are subject to the same laws and regulations as in-person care.
Payment Agreement/ Assignment of Benefits: I agree to be responsible for any co-payments, deductibles, or other charges that are not covered or paid by insurance or third party payors—except as prohibited by any state or federal law, or any agreement between my insurance company and Comprehensive Pain Solutions. I authorize Comprehensive Pain Solutions to file claims for payment of any portion of the patient’s bills, and assign all rights and benefits payable for healthcare services to the provider or organization providing 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 Comprehensive Pain Solutions has 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/telemedicine services are covered under my insurance plan. I understand that I may be billed and agree to pay all bills submitted by, Comprehensive Pain Solution and/or other providers involved with the provision of telehealth/telemedicine services.
Consent to be Contacted (Telephone Consumer Protection Act): By providing a telephone number for cellular phone or other wireless device, I agree that, Comprehensive Pain Solutions may service my account(s) (including contacting me about appointment reminders, surveys, obtaining potential financial assistance for my account(s)), or to collect any amounts that I may owe. I expressly consent that methods of contact may include SMS text messages, phone calls, including automated technology such as an auto-dialing device, pre-recorded messages, and artificial voice messages as applicable. This consent applies to all services and billing associated with my account(s) and is not a condition of purchasing services.
By verbal agreement, you agree to the above consent for treatment and services through Telehealth/Telemedicine