OpenLoop Healthcare Partners, PC TELEHEALTH CONSENT FORM

Last Updated: July 17, 2023

I understand that Telehealth is a mode of delivering health care services via communication technologies (e.g., internet or cellphone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

By acknowledging my consent below, I understand and agree to the following:

  1. I understand that OpenLoop Healthcare Partners, PC (“OpenLoop”) offers Telehealth consultations, which are conducted through videoconferencing, telephonic, and asynchronous technology and my Telehealth provider will not be present in the room with me.  

  2. I understand there are potential risks to the use of Telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties.  I understand that either my Telehealth provider or I can discontinue the Telehealth appointment if the technical connections are not adequate for my visit. 

  3. I understand that I could seek an in-office visit rather than obtain care from a Telehealth provider, and I am choosing to participate in a Telehealth consultation with an OpenLoop provider.

  4. To protect the confidentiality of my health information, I agree to undertake my Telehealth consultation in a private location, and I understand that my Telehealth provider will similarly be in a private location.

  5. I understand that I am responsible for payment of any amounts due and owing resulting from my Telehealth visit.

  6. In an emergent situation, I understand that the responsibility of my Telehealth provider may be to direct me to emergency medical services, such as an emergency room. 

By acknowledging below, I certify:

  • that I have read this form and/or had it explained to me

  • that I understand the risks and benefits of a Telehealth appointment

  • That I have been given the opportunity to ask questions and that such questions have been answered to my satisfaction.


AUTHORIZATION TO BILL INSURANCE AND ASSIGNMENT OF BENEFITS

The above information is true to the best of my knowledge. I authorize OpenLoop Healthcare Partners, PC (“OpenLoop”) and its affiliated entities (OpenLoop Healthcare Partners California, PC, OpenLoop Healthcare Partners, PC, INC, OpenLoop Healthcare Partners New Jersey Professional Corporation, OpenLoop Healthcare Partners, Wisconsin, S.C., OpenLoop Healthcare Partners Colorado, PC, REZILIENT OLH, PA, REZILIENT OLH ALABAMA, S.C., Rezilient OLH, COLORADO, PA, REZILIENT OLH NEW JERSEY, PA, REZILIENT OLH WISCONSIN, S.C, Reliant MD Medical Associates PLLC) directly bill my insurance company and I further authorize any third-party payer through which I have benefits to make payment directly to OpenLoop. I understand that I am financially responsible for any balance. I also authorize OpenLoop or my insurance company to use and disclose any healthcare information for the purpose of obtaining payment for services and determining insurance benefits. Services provided by outside companies (i.e. lab, pathology, radiology) are billed separately by those companies.


CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT REMINDERS AND OTHER HEALTHCARE REMINDERS

By signing below, I consent to receive text messages from the practice at my phone number or email to receive appointment reminders and general health reminders of information. I understand that this request is to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information.