1. I voluntarily consent to medical care recommended by the medical provider including, x-rays, heart tracings, medications, and/or routine laboratory testing (including human immunodeficiency virus infection, hepatitis, or any other blood-borne infectious disease if ordered by a clinician for diagnostic purposes).
2. I authorize the clinic to release medical information to insurance carriers for the purposes of filing insurance claims related to my/his/her medical care.
3. I agree that insurance (if applicable) will billed for services and I (patient, parent or guardian of the patient) am responsible for any charges not paid or denied by the insurance company.
4. I understand that even if you have a copy of my Advance Directive or Living Will that clinic staff will attempt to stabilize me and transfer me to an acute care hospital for further evaluation and treatment.
5. This form has been fully explained to me and I understand its contents. If you need further information, please contact ARcare Coordinated Care at 870-347-3461.
1. I authorize ARcare/MississippiCare/KentuckyCare to allow me/the patient to participate in a telemedicine/Virtual Care (videoconferencing) service with ARcare. This consent applies to both Physical and Behavioral Health Services.
a. If Behavioral Health Services is indicated or requested:
I understand that Tele-behavioral health services are completely voluntary and that I can choose not to do or not to answer questions at any time.
I understand that I will be assigned one therapist and will only see that that therapist for my behavioral health care via tele-behavioral health services in ensuring continuity of care.
I understand that I will be asked to create a safety plan with my therapist in case of an emergency.
I understand that if there's an emergency during a Tele-behavioral health session, my therapist will call emergency services and my emergency contacts.
2. The type of service to be provided via telemedicine is Acute Care Services.
3. I understand that this service is not the same as a direct patient/healthcare provider visit, because I/the patient will not be in the same room as the healthcare provider performing the service. I understand that parts of my/the patient’s care and treatment which require physical tests or examinations may be conducted by the clinical staff at my/the patient’s location under the direction of the telemedicine healthcare provider.
4. My/the patient’s physician has fully explained to me the nature and purpose of the videoconferencing technology and has also informed me of expected risks, benefits and complications (from known and unknown causes), attendant discomforts and risks that may arise during the telemedicine session, as well as possible alternatives to the proposed sessions, including visits with a physician in-person. The attendant risks of not using telemedicine sessions have also been discussed. I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily.
5. I understand that there are potential risks to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my/the patient’s healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation.
6. I understand that the telemedicine session will not be audio or video recorded at any time.
7. I agree to permit my/the patient’s healthcare information to be shared with other individuals for the purpose of scheduling and billing. I agree to permit individuals other than my/the patient’s healthcare provider and the remote healthcare provider to be present during my/the patient’s telemedicine service to operate the video equipment. I further understand that I will be informed of their presence during the telemedicine services. I acknowledge that if safety concerns mandate additional persons to be present, then my/guardian permission may not be needed.
8. I acknowledge that I have the right to request the following:
a. The omission of specific details of my/the patient’s medical history/physical examination that is personally sensitive, or
b. Termination of the service at any time.
9. When the telemedicine service is being used during an emergency, I understand that it is the responsibility of the telemedicine provider to advise my/the patient’s local healthcare provider regarding necessary care and treatment.
10. It is the responsibility of the telemedicine provider to conclude the service upon the termination of the videoconference connection.
11. I/the patient understand(s) that my/the patient’s insurance will be billed by both the local healthcare provider and the telemedicine healthcare provider for telemedicine services. I/the patient understand(s) that if my insurance does not cover telemedicine services I/the patient will be billed directly by the telemedicine healthcare provider for the provision of telemedicine services.
12. My/the patient’s consent to participate in this telemedicine service for the duration of the specific service identified above, or until I revoke my consent in writing.
13. I/the patient agree that there have been no guarantees or assurances made about the results of this service.
14. I confirm that I have read and fully understand both the above and the Telemedicine: What to Expect Form provided. All blank spaces have been completed prior to my signing.