CONSENT TO PARTICIPATE IN A TELEMEDICINE CONSULTATION AND/OR TREATMENT
CONSENT TO USE AND DISCLOSURE OF HEALTH INFORMATION
PLEASE READ THIS FOR INFORMATION ABOUT YOUR UPCOMING TELEHEALTH VISIT. YOU MAY BE ASKED BY THE PROVIDER IF YOU UNDERSTAND THIS DOCUMENT AND AGREE WITH IT. YOU MAY ASK YOUR PROVIDER ANY QUESTIONS YOU HAVE.
- I hereby voluntarily consent to the participation and treatment in a telehealth consultation and/or treatment with HearUSA, and Lifestyle Hearing Corporation (USA), Inc., their subsidiaries and/or
affiliates (the “Provider”).
- I understand that by participating in a telehealth visit, the Provider and I will communicate by teleconference or other electronic means. I understand that there are no guarantees regarding outcomes and results of these telehealth examinations and treatments.
- It has been explained to me how the teleconferencing technology will be used to conduct the telehealth visit. I understand that this telehealth visit will not be the same as an in-person visit due to the fact that I will not be in the same location as the Provider.
- I further understand that there are risks to telehealth visits, including, but not limited to, interruptions, unauthorized access, and technical difficulties. I understand that I may discontinue the telehealth visit if I feel the teleconferencing connections are not adequate for the situation.
- I understand it may be necessary and useful for others to be present during the telehealth visit in order to operate the teleconferencing equipment. I further understand and acknowledge that these individuals are bound to maintain the confidentiality of all information discussed in my telehealth visit. I further understand that if others are present, I have the right to ask that they leave the telehealth visit and/or to terminate the telehealth visit.
- I understand that the responsibility of the Provider for my telehealth visit concludes upon termination of the teleconference connection.
- I understand and consent to being recorded by the Provider during my telehealth visit and that any recording of my telehealth visit will be maintained by the Provider as confidential health information, consistent with applicable law.
- By signing this consent, I authorize the Provider to release any of my relevant health information as allowed or required by law. I further authorize the Provider to release any information to my insurance company or any other party that may be responsible for payment for my treatment.
- I have a legal right to review the provider’s Notice of Privacy Practices before signing this consent. It can be read in full athttps://www.hearusa.com/privacy-policy/ . I have the right to request this notice in a non-electronic format.
- I understand that I have the right to withdraw this consent at any time.
- I have read (or have had read to me) this document carefully, and hereby consent to participate in telehealth consultation and/or services pursuant to the terms described above.