Healthcare Virtual Services Letterhead

HEALTHCARE VIRTUAL SERVICES LETTERHEAD

Clinic Name:    Provider Name:

Credentials/NPI:    Clinic Address:

Phone:    Fax:    Email:

Virtual Services Overview

This letterhead documents the terms and patient acknowledgments for health services delivered via virtual means, including synchronous videoconferencing, telephone encounters, secure messaging, and other remote technologies (collectively "Virtual Services"). Virtual Services are provided when direct in-person care is not feasible or when both patient and provider agree that remote care is appropriate.

Patient Information

Insurance Information

Medical History (Relevant to Virtual Visit)

Technology & Patient Responsibilities

I acknowledge that I must provide a private, secure location and appropriate device and Internet access for Virtual Services. Technical failures can occur and may require rescheduling or conversion to a telephone-only visit. I am responsible for maintaining up-to-date contact information with the provider.

I acknowledge and accept the technology and location responsibilities described above.

Risks, Benefits, and Alternatives

Virtual Services may provide benefits including increased access to care and convenience. Risks include potential privacy breaches, incomplete examination due to limitations of remote assessment, and technical interruption. Alternatives include in-person evaluation, referral to local services, or deferred care.

I have been informed of the risks, benefits, and alternatives to Virtual Services and consent to proceed.

Confidentiality and Electronic Communication

Virtual Services are subject to applicable privacy laws. The provider will use reasonable safeguards to protect the confidentiality of electronic transmissions. However, absolute confidentiality cannot be guaranteed. I authorize communications concerning my care via the contact methods provided.

I understand and accept the confidentiality limitations and authorize electronic communications.

Billing, Records, and Recording

Virtual Services are billable as clinical encounters and may be billed to insurance or self-pay according to applicable policy. All encounters will be documented in the medical record. The patient must not record the encounter without prior written consent from the provider.

I acknowledge billing may apply and agree not to record encounters without consent.

Emergency Procedures

Virtual Services are not appropriate for urgent or life-threatening emergencies. If I experience a medical emergency, I will call local emergency services or proceed to the nearest emergency department. I will provide the provider with my current location at the start of each Virtual Service encounter.

I understand emergency procedures and will provide my location at the start of the encounter.

Authorization

I hereby authorize the provider identified on this letterhead to provide Virtual Services to me. This authorization includes treatment-related communications, documentation in my medical record, and electronic transmission of information necessary for treatment and billing.

I understand that I may revoke this authorization in writing at any time, except to the extent that the provider has already acted in reliance on my authorization. Revocation will not affect disclosures already made.

Patient Acknowledgment

By signing below, I affirm that I have read and understand the contents of this Healthcare Virtual Services Letterhead, that I have had the opportunity to ask questions, and that I consent to receive Virtual Services under the terms described herein.

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