I hereby consent to engage in a Virtual clinic with OPD-PKLI&RC as a part of my medical treatment. I understand that “OPD-PKLI&RC Virtual Clinic” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, education and counselling using interactive audio, video, or data communications. I understand that Virtual clinic also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located at OPD-PKLI&RC.
I hereby consent to OPD-PKLI&RC that I have the following rights and responsibilities with respect to the Virtual Clinic:
1. I hereby authorize OPD-PKLI&RC Health Care Services to use the telehealth practice platform for telecommunication for evaluating, testing, and diagnosing my medical condition.
2. I understand that the same standard of care applies to a Virtual clinic visit as applies to an in-person during his/her visit at OPD-PKLI&RC.
3. I understand that I have a right to access my medical information and copies of medical records, financial invoices, vouchers, in accordance with the policy and procedure established by OPD-PKLI&RC.
4. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended and scheduled by the healthcare professionals of OPD-PKLI&RC.
5. I accept that my healthcare professionals at OPD-PKLI&RC can contact interactive sessions with a video call. However, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
6. I understand that my current insurance may not cover the additional fees (If any) of the telehealth practices, and I may be responsible for any fee that my insurance company does not cover.
7. I agree that my medical records on telehealth can be kept for further evaluation, analysis, and documentation, and in all of these, my information will be kept private under the policy and procedures established by OPD-PKLI&RC.
8. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties during my medical treatment and interaction with healthcare professionals.
9. I understand that the laws that protect the privacy and the confidentiality of health care information apply to Virtual clinic services.
10. I understand that my healthcare information may be shared with other individuals/professional staff of OPD-PKLI&RC for scheduling and billing purposes.
11. I understand that health plan payment policies and procedures for Virtual clinic visits may be different from policies for in-person visits.
12. I understand that this document will become a part of my medical record.
I understand that Virtual clinic-based services and care may not be as complete as face-to-face services. I also understand that, if my healthcare professional believes I would be better served by another form of healthcare services (e.g., face-to-face services). I will be referred to any other healthcare institute that can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of medical treatment and that despite my efforts and the efforts of my healthcare professional, my condition may not be improved, and in some cases may even get worse. By signing this form, I hereby consent to OPD-PKLI&RC that;
1. I have personally read this form (or had it explained to me) and fully understand and agreed with its contents.
2. I have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to Virtual clinic visits shared with me in a language I understand.