Virtual Visit Consent
WHAT A TELEMEDICINE VISIT IS?
A telemedicine (Virtual Visit) is a medical visit conducted by live two-way video, or by telephone where my provider determines that is clinically appropriate. Vitality Urgent Care conducts virtual visits only on secure, HIPAA-compliant platforms approved by the practice. The platform used for my visit is agreed between me and my provider, based on what is secure and workable for both of us.
LIMITATIONS I UNDERSTAND
My provider cannot physically examine me. There is no ability to listen to my heart or lungs, palpate an area, or perform any hands-on assessment. No laboratory tests, imaging, injections, or procedures can be done during a virtual visit. My provider may be unable to reach a diagnosis and may direct me to be seen in person, at an emergency department, or by another provider. A virtual visit is not a substitute for care from a primary care physician.
MY LOCATION
I confirm that I will be physically located in Illinois for the entire duration of every telemedicine visit under this consent. If I am outside Illinois, the visit cannot be conducted and will be rescheduled or redirected to local care.
EMERGENCIES
A telemedicine visit is not for emergencies. If I am having chest pain, difficulty breathing, signs of stroke, severe bleeding, a severe allergic reaction, or thoughts of harming myself, I will call 911 or go to the nearest emergency department rather than start or continue a virtual visit.
IF THE TECHNOLOGY FAILS
If the connection fails and cannot be restored, my provider will attempt to reach me at the phone number on file and may complete the visit by telephone. If the visit cannot be completed, I will not be charged for it.
PRESCRIPTIONS
My provider may prescribe medication if clinically appropriate. Controlled substances are never prescribed during a telemedicine visit at Vitality Urgent Care, under any circumstance. My provider is not obligated to prescribe any medication I request.
PRIVACY AND MY RECORD
The platform used is HIPAA-compliant and my information is protected the same as during an in-person visit. I am
responsible for choosing a private location on my end; Vitality Urgent Care cannot control who is within earshot where I am. A complete record of this visit is created in my chart, and I have the same right to access it as any other visit.
MY RIGHTS
I may decline a telemedicine visit, or stop it at any point once it has started, without penalty and without affecting my future care. I may instead be seen in person at Buffalo Grove or Lake Zurich. I may ask questions at any time.
COST
A telemedicine visit is billed as a medical visit. Copays, deductibles, and coinsurance apply. Coverage for virtual visits varies by insurance plan, and I am responsible for any balance my plan does not cover.
AI-ASSISTED DOCUMENTATION
Vitality Urgent Care uses AI-assisted documentation, a tool now common in medical practice. At the start of each visit I will be told that it is in use. The conversation is captured and processed by the practice’s documentation vendor, which operates under a written agreement with Vitality Urgent Care, to prepare a draft note. I may opt out at any time by telling my provider, before or during the visit. My care will not be affected, and my provider will document the visit manually. I have read and understand the above. I consent to receive care by telemedicine from Vitality Urgent Care. This consent remains in effect for 12 months from the date signed unless I withdraw it.
