I understand that telemedicine or telehealth is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider.
I understand that telemedicine or telehealth visits are reserved for mild to moderate conditions and may not be appropriate for severe or life-threatening illnesses.
I understand that medical evaluation, diagnosis and treatment offered on kwikcare providers are virtual or asynchronous in the absence of a face to face physical examination.
I agree to call 911 or seek emergency care if your symptoms or condition worsen or immediate medical is required after your telemedicine visit.
I agree to continue the recommended routine physical visit with an in-person physician while utilizing telemedicine as secondary means of accessing healthcare.
I certify that I do not have any cognitive impairment and capable of making sound medical decisions.
I understand that I’m engaging in telemedicine (telehealth) consultation and I accept the risk of misdiagnosis due to the absence of in-person evaluation or diagnostic tools.
I certify that I must be an adult patient or an adult legal guardian of a minor patient to use the Kwikcare providers platform. I understand that services rendered by Kwikcare providers are provided on a non-refundable basis.
I understand that my payment to kwikcare providers, the consultation fee, may not cover the prescribed medication and I still have to pay for the prescribe medication at the pharmacy.
I understand that I must provide Kwikcare providers with the most accurate and up to date information about my health, medical history, medications, allergy and diagnostic reports to avoid misdiagnosis.
I understand the health history, medical history, medication list, allergy list, diagnostic reports and any other information I provide to kwikcareproviders and its representative will be used to evaluate and provide my assessment and treatment plan.
I understand that, by failure to obtain or provide requested diagnostic lab or images studies may increase the risk of misdiagnosis and treatment failure.
I will not hold kwikcare providers and its representatives responsible for any misdiagnosis and treatment failure caused by failure to furnish or comply with medically necessary diagnostic studies. I hereby acknowledge that I’ll follow-up with a doctor in-person for a face to face to re-evaluation if my symptoms worsen or do not improve timely after this telehealth visit.
I understand that the consultation fee covers this only single visit, and acknowledge that a prescription refill request or re-evaluation visit on a different day may incur additional fees and charges. I have been informed that telemedicine is a supplement to, not a replacement for, in-person physician visits.
I have been informed that electronic communication via email or other asynchronous electronic medical record transfer may delay the delivery of care via telemedicine. However, it’s my responsibility to request a cancellation in order to seek immediate care elsewhere if this delay poses a health risk.
I understand that I can cancel the telemedicine visit prior to the consultation status being marked as completed. A complete status is non-refundable.
I understand that it’s my responsibility to follow-up with a doctor in-person for further evaluation, lab testing especially if my conditionals does not improve in a timely manner.
This Consent to Treat form is provided by Kwikcare Providers, a telemedicine company. By signing this form, you acknowledge your consent to receive medical treatment and services via telemedicine.
1. ACKNOWLEDGEMENT OF TELEHEALTH SERVICES: I understand that telemedicine involves the use of electronic information and communication technologies by a healthcare provider to deliver healthcare services to me. This may include the use of interactive audio, video, or other electronic media for diagnosis, consultation, treatment, transfer of medical data, and education.
2. CONSENT TO USE TELEHEALTH SERVICES: I voluntarily consent to receive healthcare services via telemedicine from Kwikcare Providers. I understand that the same standard of care applies to a telehealth visit as applies to an in-person visit.
3. PRIVACY AND CONFIDENTIALITY: I understand that Kwikcare Providers is committed to protecting the privacy and confidentiality of my health information. I acknowledge that Kwikcare Providers has provided me with a Notice of Privacy Practices that explains how my health information may be used and disclosed.
4. RISKS AND BENEFITS: I understand that there are potential risks and benefits associated with telemedicine, including but not limited to, disruption of transmission by technical failures, the potential for unauthorized access to the electronic information, and/or limitations of medical care due to the inability of physical examination.
5. RIGHT TO WITHDRAW CONSENT: I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
6. HIPAA COMPLIANCE: I understand that Kwikcare Providers is committed to complying with the Health Insurance Portability and Accountability Act (HIPAA) and has implemented several safeguards to protect my health information.
I hereby consent and authorize Kwikcare providers medical providers (which may include Medical doctors, Physician Assistants, Nurse Practitioners, and Medical Assistants) to administer and perform medical evaluation and treatment deemed necessary and release Kwikcare providers of any legal responsibility incurred by the medical providers. I understand that electronic communication technology will be used during online consultation, and such a consultation will not be the same as a direct patient-health care provider visit due to the fact that I will not be in the same room as my health care provider.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
I understand that my healthcare information may be shared with kwikcare providers medical providers and pharmacy staff for the purpose of providing appropriate medication and treatment plans. Kwikcare medical providers will all maintain the confidentiality of the information obtained. Telemedicine or Telehealth carries the risk of misdiagnosis or delayed diagnosis, which could lead to patients not receiving the proper treatment or even receiving the wrong treatment.
I understand these potential risks and am willing to proceed with a consultation with kwikcare providers. Due to the potential risk of misdiagnosis or delayed diagnosis, I understand and agree to seek immediate medical care if my symptoms do not improve within a timely manner (typically within 48 hours) I understand that the treatment, therapy or recommendations provided by kwikcare providers medical team is an initial and first-line approach and I agree to follow up with a doctor in-person for a re-evaluation as needed.
I understand that the health care provider or I can discontinue the telemedicine visit if it is felt that the electronic communication technology is not adequate for the situation.
I understand that I have the right to withdraw my consent to the use of telemedicine or telehealth at any time in the course of care. As long as the consent is in force, kwikcare providers medical team may provide health care services to me via telemedicine without the need to sign another consent form.
I have had the alternatives to a telemedicine or telehealth consultation explained to me, and I’m choosing to participate in a telemedicine or telehealth consultation.
I understand that some parts of the exam involving physical tests may be limited due to the fact that I will not be in the same room as my health care provider.
I understand that kwikcare providers utilizes both synchronized and asynchronized (store and forward) to deliver care. and I have visited www.kwikcareproviders.com to familiarize myself with these types of telemedicine practices, and their scope of practice.
I certify that I must be an adult patient or an adult legal guardian of a minor patient to use the Kwikcare providers platform. I understand that services rendered by Kwikcare providers are provided on a non-refundable basis.
I understand that my payment to kwikcare providers, the consultation fee, may not cover the prescribed medication and I still have to pay for the prescribe medication at the pharmacy.
I understand that the information given on the medical intake form must be complete, accurate and up-to-date to the best of my knowledge.
I understand that my failure to provide a complete, accurate and truthful information on the intake form puts me at a harmful risk of misdiagnosis and incomplete treatment.
I understand that Kwikcare providers reserves the right to decline treatment if misleading pieces of information are given by the patient or use By signing below,
I acknowledge that I have read and understood the information provided above, and I give my consent to receive healthcare services via telemedicine from Kwikcare Providers. For any questions or concerns, please contact our HIPAA Compliance Officer at our main phone number (7135880300) or in person.