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Virtual Health Patient Consent Form
Virtual Health lets healthcare providers care for you, even when you cannot see them in person. The providers use the Internet and other technology to conduct a patient session.

We are a HIPAA-compliant organization. Keeping your information safe is very important to us. Only authorized people can access your health data. All others are locked out. No recordings of Virtual Health sessions are made

Before you can have a Virtual Health session, your provider will decide if your health needs can be addressed this way. The final decision to participate in Virtual Health sessions is ultimately your decision as the patient. You can include other people such as a spouse, partner, parent, or another family member in your Virtual Health session

You are not allowed to make any recordings of your session.
Your Virtual Health Session
During your Virtual Health session:

•    You may be asked to confirm the state you are in and the state where you live. You may also need to show a photo
•    If the patient is a minor child, the Virtual Health provider will explain to the parent how a Virtual Health exam is
     different from an in-person session. He or she will also explain if a complete evaluation of the child is possible.
•    The provider may talk to you about your health history, exams, x-rays, and other tests. Other providers may take
     part in this discussion
•    A visual and/or partial physical exam may take place. This may happen with video, audio, and/or other technology
     tools. Healthcare staff may be in the room with you to help with the exam.
•    With your knowledge the provider may take photos.

Risks and Common Problems
Technology can make getting health care easy, but there can also be problems:

•    If there is an equipment or Internet problem, your diagnosis or treatment could be delayed.
•    Although we have security measures in place, there could be a possible risk to technology that could include
     unauthorized access to your chart. If this happens, you will be informed.
•    If there is a technology problem, it would be outside the control of your doctor and the telemedicine provider.
•    Without a hands-on exam, it may be hard to diagnose your problem.

Participation in Virtual Health Sessions in Public Locations
If you have a public Virtual Health session or are using public Wi-Fi, you must agree that:

•    You are doing so at your own risk.
•    There may be unforeseen problems, and your protected health information may be accidently shared.
•    The session is voluntary.
•    You can withdraw at any time.
•    You will sign a HIPAA release form.
•    This agreement applies to each public Virtual Health session you may have with your provider at Boice Willis Clinic

More Facts
A main goal of Virtual Health is to make sure that you get good, personal health care.

Virtual Health providers must follow the same rules for prescribing drugs just as they would for an office visit.

Having a Virtual Health session is your choice. You can stop the session at any time. You can limit the physical exam.

You will be told about all staff who will take part in the session. You can ask that any of these people leave the room to stop them from seeing or hearing the session. It is up to you to make sure the setting for your session is private. It should only include people who you are willing to share health information with. Your Virtual Health provider can ask that people with you leave the room to make sure your session is private

Your session may end before all problems are known or treated. It is up to you to get more care if your health problem does not go away.

Financial Responsibility
By signing this form, you acknowledge your responsibility for any cost associated with Virtual Health Services. Most insurers will cover professional services, equipment, testing, and other services rendered by our providers to you or one of your dependents, but there may be copays, coinsurance, or deductible costs based on your insurance policy. While Boice Willis Clinic will check your benefits and estimate your costs, we cannot guarantee coverage by or benefits of your insurance.

Boice Willis Clinic will file an insurance claim for services rendered by Boice Willis Clinic providers. You or your guardian is responsible for all financial costs that are not covered by insurance.

This agreement must be signed before continuing with Virtual Health Services, equipment, testing, or other services provided by Boice Willis Clinic licensed providers. It will be kept on file.

Patient Acknowledgment
This form gives you facts about and risks of Virtual Health sessions. By signing this form, you agree that you have read, understand, agree with these terms and

•    are signing this consent voluntarily,
•    have been able to ask questions about Virtual Health sessions, and all questions have been answered,
•    understand no guarantees have been made about success or outcome,
•    agree to take part in a Virtual Health session and understand you can withdraw at any time,
•    agree the provider can withdraw consent to use Virtual Health based on the patient,
•    have signed general consent to be treated as well as other required consents, or I consent to be treated,
•    agree to be fully open and fully disclose all health and other information,
•    are alone or will give the names of those present in the session,
•    agree to call 911 in the event of an emergency or if your provider asks you to,
•    understand that you may not make recordings of the sessions
•    understand your financial responsibilities,
•    are authorizing Boice Willis Clinic to contact insurers and that insurance benefits will be paid to Boice Willis Clinic

Click to download: Notice of Privacy Practices (Revised 6/2018)
*  By checking this box, I agree that my typed name will be considered the equivalent of my inked signature and I have downloaded a copy of the Notice of Privacy Practices.
Office Location*  
Patient First Name* Patient Last Name*
Phone* Date Of Birth*
Last 4 of SSN*
Relationship to Patient (if Responsible Party is not Patient or if Patient is a Minor)  
Parent/Guardian Name (if applicable) Date & Time