CONSENT FOR HOME-TELEHEALTH SERVICES AND TREATMENT
To our patients and families:
Thank you for choosing telehealth care though the Barbara Davis Center ("BDC"). Patients and families are essential participants in health care and we want you to understand your rights and responsibilities while receiving care from us. If you have any questions about this form, please ask your provider. If you are a parent/legally-authorized representative of a child, please read this agreement with the understanding that "I" and "me" means the child.
1. Consent for Treatment: I consent to telehealth care performed by my physician and all other associated health care providers at the BDC and/or the University of Colorado School of Medicine ("CUSOM") (the "Providers"). This includes examinations, diagnostic testing, treatment, and other health care services deemed medically necessary in the Providers' professional judgment. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may cause injury or even death. I also understand that I have the option to refuse the delivery of health care services by telehealth at any time without affecting my right to future care or treatment, and without risking the loss or withdrawal of any benefits to which I would otherwise be entitled. I understand that individuals who want to learn about the roles of healthcare providers may observe , and I consent to this but I have the right at any time to object to letting such an individual to observe and my objection will be honored. I understand that if I am participating in a research protocol and have signed a Colorado Multiple Institutional Review Board (COMIRB) consent form, all provisions or this Patient Registration and Consent for Treatment shall apply to those tests and services not included within the research protocol. If I am pregnant, this consent also applies to my fetus.
2. Consent for Telehealth Services: Telehealth involves transmission of video, photographs, and/or details of my medical record such as A1Cs, device data, and test results (collectively, "Data"). All Data is sent by secure electronic means to the Providers to facilitate the medical service being performed. I understand that:
- I will be informed of any other people who are present at either end of the telehealth encounter and have the right to exclude anyone from either location.
- All confidentiality protections required by law or regulation will apply to my care.
- I have the right to refuse or stop participation in telehealth services at any time and request alternate services such as an in-person appointment. However, I understand that equivalent in-person services might not be available at the same location or time as telehealth services.
- If I do not want to receive health care services by telehealth, it will not affect my right to future care or treatment, or any insurance/program benefits to which I would otherwise be entitled.
- If an emergency occurs during a home-telehealth encounter I should call 911 and stay on the video connection (if applicable) until help arrives.
3. Records, Transmission of Data, and Release of Information: I authorize CUSOM and its health care delivery sites to utilize confidential medical/surgery or other information contained in my medical record as necessary for claims payments, medical management, or quality of care review purposes. I further authorize the release and discharge if such confidential information to my insurance company or other health coverage plan, including government payors, as necessary for claims payments, medical management, and quality review activities conducted by such company or plan, or its designees. This authorization includes the release of an Acquired Immunodeficiency Syndrome (AIDS) diagnosis or a positive Human Immunodeficiency Virus (HIV) antibody test result, alcohol and/or drug abuse information, genetic testing, congenital disorders, and mental health information. I understand that this authorization can be revoked by me at any time in writing, but only in respect to the proposed treatment and not in respect to care or treatment that has already been rendered to me. I understand that if I am a subject in a human-subjects research protocol, my medical information may be further disclosed to agencies and individuals identified in the COMIRB consent form. Transmitted Data may become part of my medical record. Data will not be transmitted to people outside my health care team except as described below, and/or if I provide additional written consent.
- I will have access to all of the information in my medical record resulting from the telehealth services that I would have for a similar in-person visit, as provided by federal and state law.
- The Providers may use or disclose my health information for treatment, continuity of care, payment, or internal operations, or when required by law or regulation in certain unique situations.
- All releases of information are subject to the same laws and regulations as in-person care. If I am participating in a human subject research protocol, my medical information may also be released as described in the research consent form(s).
4. Waiver of Responsibility for Personal Valuables: I understand that neither the Providers nor any of their health care delivery sites assume any responsibility for the loss of damage to my personal property.
5. Payment Agreement/ Assignment of Benefits: I agree to be responsible for any co-payments, deductibles, or other charges from the Providers and their providers that are not covered or paid by insurance or other third party payors - except as prohibited by any state and/or federal law, or any agreement between my insurance company and the Providers, CUSOM, or University of Colorado Medicine (Faculty Practice Plan ("CU Medicine")). I authorize the Providers and CU Medicine to file any claims for payment of any portion of the patient bills, and assign all rights and benefits payable for health care services to the provider or organization furnishing the services. I agree, subject to state and federal law, to pay all costs, attorney fees, expenses, delinquent charges, and interest in the event the Providers and/or CU Medicine have to take action to collect the same because of my failure to pay all incurred charges in full. It is my responsibility to know what providers and telehealth services are covered under my insurance plan. I understand that I may be billed and agree to pay all bills submitted by the Providers, CU Medicine, and/or other providers involved with the provision of telehealth services.
6. Consent to be Contacted (Telephone Consumer Protection Act): By providing a telephone number (landline or cellular) or other wireless device, I agree that in order for the Providers, CU Medicine, and/or other providers involved with the provision of telehealth services to service my account(s) (including contacting me about appointment reminders, surveys, obtaining potential financial assistance for my account(s)), or to collect any amounts I may owe, the Providers, CU Medicine, and/or other providers involved with the provision of telehealth services may contact me at the telephone number(s) provided which could result in charges to me. I expressly consent that methods of contact may include SMS text messages, phone calls, including automated technology such as an auto-dialing device, pre-recorded messages, and artificial voice messages as applicable. This consent applies to all services and billing associated with my account(s) and is not a condition of purchasing services. This consent applies to any updated or additional contact information that I may provide.