Informed Consent Agreement
Last revision: March 11, 2019
Description of Services.
The Healthcare Professionals at Visit Checklist Professionals* provide healthcare services using interactive audio and video technologies where you and the Healthcare Professional are not in the same physical location. You can form an ongoing treatment relationship with a Healthcare Professional, however, your initial visit may begin as a consultation (e.g. to determine the most appropriate treatment setting for you to receive care) and will not necessarily give rise to an ongoing treatment relationship. You should seek emergency help or follow-up care when recommended by a Healthcare Professional or when otherwise needed, and continue to consult with your other healthcare providers as recommended. Among the benefits of our Services are improved access to healthcare and convenience. However, as with any health service, there are potential risks associated with the use of technology.
These risks include, but may not be limited to:
- In rare cases, information transmitted may be insufficient for healthcare decision making.
- Disruptions can occur due to failures of the electronic equipment or internet connection. If this happens, you may be contacted by phone or other means of communication.
- In rare cases, a lack of access to all of your health records may result in adverse drug interactions or other errors.
- Although we incorporate strong security protocols to protect the confidentiality of your health information, in rare instances security protocols can fail, causing a breach of confidentiality.
- By accepting this consent you acknowledge that you understand and agree with the following:
- We may share information about the health care services you receive from us with your health insurance company. This may include information relating to genetic testing, substance abuse, mental health, communicable diseases and other health conditions, subject to the terms in our Privacy Policy.
- If your health insurance coverage does not pay for your Services charges in full, you may be fully or partially responsible for payment.
- Our Health Professionals may share your health records with other health care providers for purposes relating to the provision, coordination or management of your healthcare so that we can meet your healthcare needs. This may include information relating to genetic tests, substance abuse, mental health, communicable diseases and other health conditions, subject to the terms in the Visit Checklist Privacy Policy.
- We may determine that our clinical services are not appropriate for some or all of your treatment needs and may elect not to provide clinical services to you through the Site.
- With respect to psychotherapy, you are entitled to receive information from your Healthcare Professional about the methods of therapy, the techniques used, the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time.
- You attest that you have legal authority to act as guardian or personal representative of all children registered under your Account.
- No results can be guaranteed or assured.
- Group Therapy.
If you and a Healthcare Professional decide to engage in group or couples therapy (collectively “Group Therapy”), you understand that information discussed in Group Therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving Group Therapy participants. You agree not to subpoena the Healthcare Professional to testify for or against other Group Therapy participants or provide records in court actions against other Group Therapy participants. You understand that anything any Group Therapy participant tells the Healthcare Professional individually, whether on the phone or otherwise, may at the therapist’s discretion be shared with the other Group Therapy participants. You agree to share responsibility with the Healthcare Professional for the therapy process, including goal setting and termination.
Messaging
You can send messages to a Healthcare Professional by contacting our Member Support team at 1-800-997-6196. Emails or electronic messages to Member Support or a Healthcare Professional may not be returned immediately. If you are experiencing a medical emergency, you should call 911 or go to the nearest emergency room.
*Visit Checklist Healthcare Professionals practice within a group of independently owned professional practices collectively known as “Visit Checklist Professionals”.