Physician360 Consent Form
Consent to Medical Care: The undersigned consents to care provided during this physician-patient interaction, which may include but is not limited to laboratory procedures, medical treatment and services rendered to the patient under the general and special instructions of the patient’s physician.
Release of Information: I agree that Physician 360 may disclose my ‘protected health information’ (PHI) in compliance with HIPAA Privacy Provisions which may include my medical records to any third-party payers, including but not limited to health insurers, health care service plans, state and federal agencies, workers compensation carriers, manufacturers required by FDA to track medical devices, or my employer. This includes appropriate release of and disclosure of my medical records in compliance with Privacy Provisions to my physicians and other health care providers when necessary for my treatment and general health. Physician 360 has permission to disclose pertinent information to family members, friends or designated caregivers who may be present with me during the video encounter or laboratory test procedures. I understand that if I am not present in the video viewfinder, my personal health information will not be disclosed or discussed unless I agree to disclose.
Video Encounter Privacy: Physician 360's interactive platform is HIPAA compliant. However, in the event that our platform is experiencing a technical error, or is incompatible with your personal computer system, it may become necessary to transition to an alternative platform that is not properly encrypted or HIPAA compliant. While we do not store any of the information transmitted during that encounter, making a breach of confidentiality unlikely, we cannot guarantee that individuals outside of our company will not be able to gain access to a patient's medical information. In the setting of technical difficulties which would preclude the use of our HIPAA compliant platform, the physician will give you the option to use a non-HIPAA compliant platform. Of course, it is always your right to discontinue the encounter and seek medical care elsewhere.
Personal Valuables: Physician 360 shall not be liable for the loss or damage to any money, jewelry, documents, furs, fur coats, electronics, garments, other articles of unusual value and small size or any personal property by the medical products being used in the home setting. Patient agrees to keep medical products away from valuable and out of the reach of children or pets.