Disclaimer

In proceeding with the content and application of this product, I acknowledge:

I am 18yrs or older

If I am below 18yrs old, an adult caregiver will be my chaperone during the session

I will be searching for out-of-network providers

Out-of-pocket purchasing will be involved, via valid credit card transactions in a third-party payment portal

My present health condition is non-emergency/acute

I am seeking non-clinical & non-diagnostic guidance  

No prescription will be provided in any form

My interest is purely in consultation/counseling/remote second opinions 

I understand that I will be interacting with verified & certified health specialists, who are not liable for litigations for adverse outcomes that is due to my own choices  

Digital health is ideal for chronic disease management and lifestyle guidance

No personal health data will be asked for nor recorded on the website, email correspondence or web chat 

The video sessions are fully encrypted and recorded upon my request.

I am not obligated to follow any advice communicated to me

I must provide an honest recollection of appropriate information as per request, to the best of my abilities

My healthcare provider and I wish to engage in a telehealth consultation. 

I understand that telehealth sessions typically last approximately 40 minutes due to the limitations of the telehealth software. 

My health care provider has explained to me how the video conferencing technology will be used and that 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 health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. 

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. 

I have had the alternatives to a telemedicine consultation explained to me. 

I had the opportunity to ask questions in regard to this procedure. 

I understand that my insurance may not cover services provided via telehealth. I agree to leave a credit card on file to pay the fees for service. 

I have the right to refuse any procedure or treatment. 

I have the right to discuss all medical treatments with my provider.

I will abide by the terms and conditions of ViOS, Inc.

 

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HIPAA Information and Consent Form 

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. 

 

What this is all about: 

Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as a patient. We balance these needs with our goal of providing you with quality professional service and care. 

 

Additional information is available from the U.S. Department of Health and Human Services.www.hhs.gov 

 

We have adopted the following policies: 

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 

 

  1. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 

 

  1. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 

 

  1. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties. 

 

  1. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor. 

 

  1. Your confidential information will not be used for the purposes of marketing or advertising products, goods, or services. 

 

  1. We agree to provide patients with access to their records in accordance with state and federal laws. 

 

  1. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient. 9. You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request. 

For more information, leave us a message at [email protected]