Consent And Understanding
This consent is required by the Health Insurance Portability & Accountability Act (HIPAA) of 2004 to inform you of your rights to privacy with respect to your health care information.
Consent for Care:
I, with my signature, authorize NP Health Clinic and any employee working under the direction of the Nurse Practitioner to provide medical care for me, or to this patient for whom I am the legal guardian.
This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and sale and dispensing of drugs, devices, equipment, or other items required and in accordance with a prescription.
This consent includes contact and discussion with other health care professionals for care and treatment.
Financial Policy:
We appreciate you choosing us for your health care. We will adhere to the following financial policy in order to consistently deliver high quality care and services. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received.
I understand that I am responsible for all payments or charges incurred from services received.
I understand that my contract with my insurance entity may or may not cover some services. All insurance policies are not the same — they vary by employer group. Practitioners in NP Health Clinic Inc. are not responsible or able to know every policy available. It is my responsibility to verify applicable coverage prior to receiving the services.
For example, not all health care plans include screenings as a benefit. If I seek care outside of the contract terms, I am aware that I may be responsible for all charges that are incurred.
Practitioners in NP Health Clinic Inc. is a Nurse Practitioner owned and operated business.
Thank you for your understanding and cooperation with this policy. It is our privilege to provide your medical care.
I have read and understood the Consents and Financial Policy stated above and agree to accept full responsibility as described above.
Telemedicine Consent Form
I authorize NP Health Clinic to utilize telemedicine technologies in determining my diagnosis and/or treatment. I understand telemedicine means the practice of healthcare delivery, diagnosis, consultation, treatment, and transfer of medical data through interactive audio, video, or data communications that occurs in lieu of the physical presence of the patient or MD/NP.
NP Health Clinic
www.nphealthclinic.ca
Phone: 289-404-4763
Will be consulted through audio, video, or data imaging and communications.
Benefits
The reason telemedicine is being utilized is for the following reason(s):
- Convenience of encounter for the patient.
- Access to healthcare technology not physically readily available.
- Need for expertise from a consultant not readily available.
Risks
The reasonably foreseeable risks of utilizing telemedicine technologies may include:
- Audio or visual images may not be as good as in person.
- Telemedicine Nurse Practitioner cannot utilize the senses of touch and smell to assist in diagnosis, treatment, or therapy.
- Telemedicine Nurse Practitioner cannot obtain their own set of vital signs.
Alternatives
The possible alternatives may be:
- Travel distance to physically see my NP/healthcare provider or undergo testing/procedure.
- Undergo therapy available locally which may not produce desired result.
- Go to local urgent care or emergency room.
Confidentiality
I understand every reasonable effort will be made to protect the security and confidentiality of my medical information, which is copied and forwarded to the above-named office, either through the mail or transmitted through electronic means as part of telemedicine.
Do not sign unless you have read and thoroughly understand this form.
