I consent to Spectrum Health and the healthcare provider assigned to me today ("Provider") to provide health care services through the use of live, two-way video (visual) and/or audio (sound) and other computer-based services.
- I understand that the electronic services allow Provider to obtain information about my health status through electronic communications for the purpose of diagnosing and determining a treatment plan for certain non-emergency conditions.
- I understand that the information provided or exchanged for an eVISIT or Video Visit may be used for diagnosis; treatment plan development and review; and case management; and may include any or all of the following electronic communications: patient medical record documentation, live two-way video and audio files and transmission of images and other data.
- I also understand that the electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient information, and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. However, I understand that all technology has risks, and that these risks include, but may not be limited to, the following: failures of the equipment or transmission may interfere with medical decision-making leading to misdiagnosis or missed diagnosis; security protocols could fail, or either party could fail to identify all participating individuals in remote locations causing a potential breach of privacy of personal medical information; a lack of access to complete medical records may result in misdiagnosis, adverse drug interactions or allergic reactions or other judgment errors; and distortions of sound, color or other transmission distortions could complicate communications, leading to misunderstanding of information. Although precautions are taken to protect the confidentiality of information, I understand that there may be risks to the confidentiality and security of my personal information that cannot be anticipated or wholly protected against at this time.
- I acknowledge that neither Spectrum Health nor the Provider(s) have made any representations, warranties, or guarantees as to the results or cures to me, and I have not relied upon any such representations, warranties, or guarantees. I understand that I can get medical care from other sources, including standard face-to-face visits at my doctor's office. I freely consent to the provision of the forthcoming services.
As with any use of technology, there are potential risks associated with the use of the electronic care services. I understand that these risks include, but may not be limited to, the following risks:
- Delays or errors in medical evaluation and treatment could occur due to deficiencies or failures of the equipment
- Information transmitted may not be sufficient to allow for appropriate medical decision making.
- Security protocols could fail, or either party could fail to identify all participating individuals in remote locations causing a potential breach of privacy of personal medical information.
- A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
- Although precautions are taken to protect the confidentiality of information new security threats can develop. I understand that there may be other risks to the confidentiality and security of my personal information that neither Spectrum Health nor I can anticipate at this time.
- The Provider can discontinue the eVISIT or Video Visit session if it is felt that the connections are not adequate for the situation.
By signing this consent, I understand and agree to the following: Notice of Nondiscrimination
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to eVISITS and Video Visits. eVISITS and Video Visits follow the Spectrum Health Notice of Privacy Practices ("SH NOPP") in using and disclosing my personal information consistent with applicable law. I acknowledge that the SH NOPP has been provided to me and that I can ask for a copy of the SH NOPP at any time.
- I understand that I do not have to use eVISITS or Video Visits; it is my choice to use electronic services.
- I understand that Video Visits use basic video (visual) and audio (sound) computer technology to provide care. I agree to hold Spectrum Health and their employees, agents and affiliates harmless for information lost due to technical failures.
- I also understand that the Provider will document the services I receive in my Spectrum Health electronic medical record.
- I understand that electronic communications of my identifiable protected health information may occur to health care providers who may be located in other areas, including out of state, and that computer transmissions may be routed outside of the U.S.
- I understand that no results can be guaranteed or assured.
- I understand that a facility fee will apply to electronic visits, which may or may not be covered by my insurance company or other third-party payers. I understand that insurance companies and third party payers, including Medicare and Medicaid, may not pay for electronic visits. If my insurance company or third party payor does not pay for an electronic visit, I understand that I am responsible for paying for the eVISIT or Video Visit. Depending on who my insurance company or third party payor is, I will receive some additional information about my financial responsibility before I have my electronic visit. I also understand that I may be billed according to the policies of Spectrum Health if I am late or fail to show up for a scheduled electronic session.
- I understand that the Provider may terminate an eVISIT or Video Visit if the Provider determines that my condition requires immediate in-person care, or otherwise determines that an eVISIT or Video Visit is not appropriate to meet my healthcare needs. The Provider may also terminate the electronic visit if I act inappropriately and do not correct my behavior when asked to do so. In such cases, I understand that it is my responsibility to obtain appropriate follow-up care.
eVISIT and Video Visit services are located in the State of Michigan, and is intended for care of patients located in Michigan. If you are not located in Michigan, you agree to advise the Provider, and the Provider may advise you to obtain care in your current location.
You agree that Providers will not prescribe certain types of medicines, including controlled substances. You agree that any prescriptions you receive from an electronic visit will be used only by you, for your healthcare needs.
I have read this document carefully, and understand the risks and benefits of the electronic services, and wish to obtain services through an electronic visit. I hereby consent to the provision of care through eVISITS or Video Visits, to the transmission of my healthcare information through electronic means used by Spectrum Health, and to the transmission of prescriptions electronically. I agree to pay for the electronic services rendered.
By replying to this email I hereby state that I have read, understood, and agree to the terms of the document "INFORMED CONSENT FOR VIDEO VISIT SERVICES".
Spectrum Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Spectrum Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact Spectrum Health Language Services at 616.267.9701, 1.844.359.1607 (TTY:711)
If you believe that Spectrum Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Director, Patient Experience
100 Michigan St NE, MC 006
Grand Rapids, MI 49503
616.391.2624; toll free: 1.855.613.2262
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Director of Patient Experience is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW, Room 509F, HHH Building
Washington, DC 20201
1.800.368.1019, 800.537.7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
ATENCIÓN: Si usted habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.844.359.1607 (TTY: 711).
.(رقم هاتف الصم والبكم: 711).
1.844.359.1607 برقمملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل
中文 (Chinese): 國語/普通話 (Mandarin), 粵語 (Cantonese)
Tiếng Việt (Vietnamese)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1.844.359.1607 (TTY: 711).
Ako govorite srpsko (Serbian, Croatian or Bosnian)
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1.844.359.1607 (TTY: 711). (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1.844.359.1607. (መስማት ለተሳናቸው: (TTY: 711).
ध्या या दनुहोस्: तपाइले नेपाल बोल्नुह ्नुह्नुह ्नुहुन भने तपाइको निम् भाषा सहायता सेवाहर नःशुल् रूपम उपलब् छ । फोन गनुर्होस ्होस ्होस ्होस 1.844.359.1607 (टटवाइ: (TTY: 711).
Thuɔŋjaŋ (Nilotic – Dinka)
PIŊ KENE: Na ye jam në Thuɔŋjaŋ, ke kuɔny yenë kɔc waar thook atɔ̈ kuka lëu yök abac ke cïn wënh cuatë piny.
Yuɔpë 1.844.359.1607 (TTY: 711).
KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo.
Piga simu 1.844.359.1607 (TTY: 711).
1.844.359.1607 تماس بگيريد. (TTY: توجه: اگر به زبان فارسی گفتگو می کنيد، تسهيلات زبانی بصورت رايگان برای شما فراهم می باشد. با .( 711
ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le 1.844.359.1607 (TTY: 711).
1.844.359.1607 (TTY: 711)
توجه اگر به زبان دری صحبت می کنيد، خدمات کمک زبانی بصورت رايگان برای شما در دسترس است. تماس با
.(TTY: 711) 1.844.359.1607
Kreyòl Ayisyen (Haitian Creole)
ATANSYON: Si ou pale Kreyòl Ayisyen, gen èd nan lang ki disponib gratis pou ou. Rele nimewo 1.844.359.1607 (TTY: 711).
ICYITONDERWA: Niba uvuga ikinyarwanda, serivisi z’ubufasha ku byerekeye ururimi, urazihabwa, ku buntu. Hamagara 1.844.359.1607 (ABAFITE UBUMUGA BW’AMATWI BIFASHISHA ICYUMA CYANDIKA -TTY: 711).
DIGTOONI: Haddii aad hadasho Soomaali, adeegyada caawimada luqadda, oo bilaasha, ayaad heli kartaa. Wac 1.844.359.1607 (TTY: 711).
انتباه: إذا كنت تتحدّث اللهجة السودانية، خدمات المساعدة بلغتك متاحة مجاناً. اتصل على الأرقام
.( 1.844.359.1607 (رقم الصم والبكم: 711
கவனம: நங்க [தமிழ] ேபசினால, உங்கக இலவசமான ெமாழி உதவச ேசைவகள கிைடக்க க்க க்க ின். இந் எண்ை அைழக் க் க�: 1.844.359.1607 (TTY: 711).
ትኹረት: ትግርኛ እንድሕር ትዛረብ ኮንካ፣ ናይ ቋንቋ ደገፍ ኣልግሎታት፣ ብናጻ ክቐርቡልካ እዮም። ደውል 1.844.359.1607 (TTY: 711)።