Healthcare Virtual Services Agreement

HEALTHCARE VIRTUAL SERVICES AGREEMENT

This Healthcare Virtual Services Agreement (the Agreement) is entered into by and between:

Provider Name:

Clinic/Organization (if applicable):

Patient Name:

Effective Date:

1. Scope of Virtual Services

Provider will deliver clinical services to Patient via secure electronic communications, which may include synchronous audio/video consultations, asynchronous secure messaging, remote monitoring, and other telehealth modalities (collectively, Virtual Services). Provider will determine clinically appropriate modalities and may combine Virtual Services with in-person care as needed.

2. Patient Information

Month:    Day:    Year:

3. Emergency Contact

4. Insurance Information

5. Medical History (Relevant to Virtual Services)

6. Technology and Privacy

Provider will use commercially reasonable administrative, physical, and technical safeguards to protect Patient information. Virtual Services may be provided using secure video platforms, telephone, or encrypted messaging. Patient acknowledges that no electronic system is completely secure and that there are inherent risks to transmission of health information via electronic means.

Patient represents that they have access to compatible technology (camera-enabled device and internet or telephone access) and agrees to maintain privacy during Virtual Services sessions. Provider will attempt to maintain confidentiality but will notify Patient of any suspected breach as required by law.

7. Patient Responsibilities

Patient agrees to: (a) provide complete and accurate medical history and medication list; (b) ensure an appropriate private setting for sessions; (c) follow instructions provided by Provider for preparation of Virtual Services; and (d) inform Provider promptly of any changes in health status.

8. Consent to Virtual Services

Patient hereby consents to receive Virtual Services as described in this Agreement. Patient consents to the following modalities (select all that apply):

Audio and Video Conferencing    Audio Only Telephone    Secure Messaging / Asynchronous Communication

Patient acknowledges that Provider has explained the expected benefits, material risks, and potential alternatives to Virtual Services, and that Patient has had an opportunity to ask questions and receive answers adequate to make an informed decision.

9. Fees, Billing and Insurance

Patient understands that Virtual Services may be billed to insurance or directly to Patient. Patient is responsible for co-payments, co-insurance, deductibles, and any services not covered by insurance. Provider will provide standard billing statements. Payment policies applicable to in-person care apply to Virtual Services unless otherwise agreed in writing.

10. Limitations and Emergency Situations

Virtual Services are not appropriate for emergencies. If Patient is experiencing a medical emergency, Patient should call emergency services or go to the nearest emergency facility. Provider will make reasonable efforts to determine Patient location at the start of each session and to transfer care or arrange local emergency services if clinically necessary.

11. Records and Authorization

Virtual Services become part of the medical record. Patient authorizes Provider to document Virtual Services and to release records to other treating providers or as required by law. Patient may request copies of records in the usual manner.

12. Termination

Either party may terminate Virtual Services at any time upon notice. Termination does not relieve Patient of financial obligations for services rendered prior to termination. Provider may terminate or suspend Virtual Services when clinically appropriate or in accordance with Provider policies.

13. Dispute Resolution and Governing Law

Any disputes arising out of or related to this Agreement shall be subject to the dispute resolution provisions set forth by Provider policies and applicable law. This Agreement shall be governed by the laws of the state in which Provider maintains its principal practice, without regard to choice-of-law principles.

14. Indemnification

Patient agrees to indemnify and hold harmless Provider, its officers, employees, and agents from third-party claims arising from Patient's use of Virtual Services, except to the extent such claims result from Provider's willful misconduct or gross negligence.

15. Acknowledgments and Certifications

By signing below, Patient certifies that they understand the nature of Virtual Services, have had an opportunity to ask questions, and voluntarily consent to treatment via telehealth modalities. Patient acknowledges receipt of Provider's privacy practices and consents to electronic communications for appointment scheduling and clinical follow-up where applicable.

HIPAA Privacy Notice Acknowledgment: I acknowledge that I have been provided with or offered the Provider's Notice of Privacy Practices describing how my health information may be used and disclosed.

16. Additional Notes / Special Instructions

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