Bridge Direct Primary Care, LLC

Informed Consent and Agreement for Telemedicine Services

Consent to Telemedicine

I understand and agree  that  by checking the appropriate box below, I am indicating my consent to receive telemedicine services. The checked box below constitutes my legal signature and indicates that I understand and agree to the terms of this document.

Definition of Telemedicine

For the purpose of this document, telemedicine is defined as the electronic communications technologies used by staff and physicians of Bridge Direct Primary Care, LLC to enable them to obtain information and communicate remotely in order to provide patient care. However, the same standard of care applies to treatment obtained through telemedicine communications as applies to an in-person visit. The information obtained through telemedicine communications  may be used for diagnosis, treatment, follow-up and/or education, and may include any of the following:

●      Patient medical records

●      Medical images

●      Live two-way audio, video and data communications

●      Output data from medical devices and sound and video files

●      Questionnaires, email and text messaging

The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Possible Benefits of Telemedicine

·      Easier access to medical care;

·      Convenience;

·      More time efficient medical evaluation and management

Possible Risks of Telemedicine

As with any technology used in medical care, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

·      Information transmitted may not be sufficient to allow for appropriate medical decision making by the physician;

·      Physician may not be able to provide medical treatment for your particular conditions remotely;

·      Regulatory and other requirements may limit your physician’s  ability to provide certain treatment options, including prescriptions;

·      Delays in medical evaluation and treatment could occur due to deficiencies or failures in technology equipment;

·      Security protocols could fail, resulting in privacy breaches of personal medical information.

Additional Understandings

1.    I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit. 

2.    I understand that I will not be physically in the same room as my physician. I will be notified if anyone other than my physician shall be present in the room. 

3.    I understand that if it is determined that the videoconferencing equipment and/or connection is not adequate, my physician or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

4.    I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

5.    I understand that I may revoke my consent at any time by contacting Bridge Direct Primary Care. LLC at info@bridgedpc.com or (678) 632-3059.

6.    I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.

7.    I understand that Bridge Direct Primary Care, LLC does not participate in or bill any insurance of health plans.

8.    I understand that the services that I receive are offered on a cash pay, fee for service basis only.

9.    I understand that this document will become a part of my medical record.  

Payment

I understand the telemedicine visits shall be charged at $150 visit. This payment includes the consult or virtual visit only and does not include  precriptions or products and services which are not personally provided by staff of Bridge Direct Primary Care, LLC.

I agree that  payment will made by credit card, debit card, or electronic bank transfer and that payment is expected at time of service.

 I certify by checking the box below, that I have read and understand this Informed Consent document. I have had an opportunity to have any of my questions answered so that I understand this document in its entirety and I request and give my consent to participation in Telemedicine. I understand that I may receive a hard copy of this Informed Consent upon request.