Introduction
The purpose of
this consent form is to provide you with information about telehealth
and to obtain your informed consent for healthcare services delivered
by eye care providers through online platforms owned and operated by
EyeQue or its subsidiaries (“EyeQue”). EyeQue is not a
healthcare provider.
Telehealth
involves the use of electronic communications (e.g. secure video
conferencing, phone calls, text messaging) to provide healthcare
services remotely. This includes consultation, diagnosis, treatment,
education, and follow-up care. Telehealth allows you to receive care
without needing to visit a healthcare facility in person. Services
available through the EyeQue platform include refraction services and
non-urgent eye related concerns.
If you believe
your eye condition is an emergency, please call your eye care
provider, head to the nearest emergency room, or call 911.
Please read this
form carefully. Your digital signature below indicates that you
understand and agree that your eye care provider will provide you
healthcare services via telehealth using the platform.
Benefits of
Telehealth Services
Receiving eye
care services through telehealth technology has many benefits,
including improved access to eye care, convenient appointment times,
and receipt of care from the comfort of home or other convenient
location.
Potential
Risks
By agreeing to
receive eye care services through telehealth technology you
acknowledge the following:
Your
provider uses a technology service called EyeQue. EyeQue’s
telehealth technology is designed to protect patient privacy.
However, as in all healthcare situations, it is possible that
security protocols could fail which may expose your medical
information.
Because
telehealth services are performed remotely, providers may be unable
to perform a full physical examination or assessment. This service
is not a replacement for a comprehensive eye examination.
If a
comprehensive eye examination is needed, or if certain symptoms or
conditions are discovered, then the provider may advise that you
should seek an in-person examination. Not all conditions can be
evaluated or treated by telehealth.
In rare
instances, information transmitted (e.g., poor resolution of images,
audio failure, etc.) may not be sufficient to allow for appropriate
medical decision making by the health care provider and may cause
delays or disruptions in your services. If this happens, an
additional attempt may be needed to complete the service.
The
inability to conduct tests or assess vital signs in person may
prevent healthcare providers from providing a diagnosis, treatment,
or from identifying a need for emergency medical care.
A lack of
access to all your medical records may result in gaps or errors. It
is important that you provide complete and accurate information to
your eye care provider.
Data and
information stored and shared electronically, such as through email
or text, may be more susceptible to unintended disclosure of health
information or other personal information to third parties.
Patient Rights
By indicating
below that I accept this consent, I agree that I understand that I
have the right to:
Receive
clear information about my care.
Choose
whether to participate in telehealth or seek in-person care.
Withdraw my
consent to telehealth at any time without affecting my right to
future care or treatment.
Patient
Responsibilities
I
understand that eye care services and treatment are the result of a
collaborative relationship between me and my eye care provider. By
using EyeQue services I agree that I will:
Provide
accurate and complete information about my health history, along
with any relevant conditions or treatments.
Promptly
pay for the services I receive. I understand that EyeQue will not
bill insurance, and I hereby release EyeQue to charge me directly
for the services I receive via the EyeQue telehealth service.
Review
and be subject to EyeQue policies and procedures. I understand I can
find those policies at [INSERT
LINK].
Privacy and
Confidentiality
Your privacy and
confidentiality are important to us. Telehealth sessions are
conducted using our secure platform to protect your information and
healthcare data. EyeQue and your provider will not share your
information unless it is permitted or required by law.
Consent to
Telehealth Services
By checking the
box below and typing my full name, I acknowledge:
I have read
and understood the information provided above, including the
potential benefits and risks of telehealth eye care services.
I have had
an opportunity to ask questions about telehealth and received
satisfactory answers.
Services
provided via the EyeQue telehealth service are not intended to treat
urgent or emergency conditions. If I am experiencing a medical
emergency or urgent condition, I will contact appropriate emergency
response and seek care in person.
It
is my duty to provide my eye care provider with truthful, accurate,
and complete information, including all relevant information
regarding care that I receive or may be receiving from other
healthcare providers, including other eye care providers.
My
eye care provider will assess my condition and provide eye care
services, and may determine, in their sole discretion, it is
appropriate to provide the services through telehealth. By
continuing to use the service, I indicate that I agree with the
provider’s assessment and agree to receive eye care services
through telehealth.
My
eye care provider may, in their sole discretion, determine that my
condition is not suitable for services through telehealth, and that
I may have to seek treatment from a specialist or eye care provider
outside of this telehealth service.
I
understand that no guarantees have been made to me as to the outcome
or result of my use of the services.
Services
will be provided by a qualified provider, and I have access to
information about the professional credentials of my provider.
I understand
and consent that any prescription or communication regarding the
telehealth visit will be provided digitally.
I
voluntarily consent to receive healthcare services via telehealth.
