Informed consent Epione Medical Care Facilities VBA d.b.a. Medcare Clinic

What This Informed Consent Covers

Throughout this Informed Consent form we’ll refer to our company and websites and other products and services collectively as “Epione Medical Care Facilities VBA d.b.a. Medcare Clinic.”

Purpose of this form. This form is provided to you as a patient of Epione Medical Care Facilities VBA d.b.a. Medcare Clinic (“Epione Medical Care Facilities VBA d.b.a. Medcare Clinic”) to inform you about the care and treatment that you may receive from Epione Medical Care Facilities VBA d.b.a. Medcare Clinic and to obtain your consent to allow Epione Medical Care Facilities VBA d.b.a. Medcare Clinic to provide care and treatment. For patients under the age of 18, or other individuals who may not be capable of making informed choices about their healthcare, this form is provided to their parents or guardians for evaluation on behalf of the patient.

Acceptance of General Terms & Conditions. By signing this form I acknowledge and confirm that I have been provided with a copy of Epione Medical Care Facilities VBA d.b.a. Medcare Clinic’s General Terms & Conditions and ample opportunity to take due note of the contents thereof and I accept the applicability thereof to my treatment agreement and relationship with Epione Medical Care Facilities VBA d.b.a. Medcare Clinic.

General consent for performance of treatment agreement. I understand that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic requires consent of the patient, and may require the consent of a parent or guardian, for the performance of the treatment agreement in respect of the patient. By signing this form, I consent to the performance of the treatment agreement and to the rendering of such care and provision of medical treatment and procedures by or on behalf of Epione Medical Care Facilities VBA d.b.a. Medcare Clinic as discussed with me by the physician. I understand that a medical record will be prepared and maintained about me by Epione Medical Care Facilities VBA d.b.a. Medcare Clinic.

Consent to share health information. I understand that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic may share my health information with other physician offices, pharmacies, labs, hospitals and/or insurance companies for treatment, payment and health care operations. I also understand that if I receive treatment for a work-related injury or illness, some of my  information will be shared with my employer or its workers’ compensation insurance carrier, in connection with evaluation of my claim, and in order to help my employer address any safety issues at the workplace. I also understand that if I request special accommodations based upon a disability, a limited amount of my medical information may be shared with my employer, to the extent warranted to evaluate or confirm my disability. By signing this form, I consent to the use and disclosure by Epione Medical Care Facilities VBA d.b.a. Medcare Clinic of my health or medical information for these purposes.

Consent to leave messages. By signing this form, I consent to Epione Medical Care Facilities VBA d.b.a. Medcare Clinic leaving messages with members of my household or on my answering machine for the purpose of reminding me that I have an appointment, to notify me that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic would like to discuss lab or procedure results or to ask me to call Epione Medical Care Facilities VBA d.b.a. Medcare Clinic regarding an issue or concern.

Consent to communicate via SMS/Email. Although I understand that it is Epione Medical Care Facilities VBA d.b.a. Medcare Clinic’s practice to convey test results to patients in person or by phone and that I always have the option to make an appointment to come in to discuss my health issues or test results in person, by signing this form, I also consent to communication via non-secure electronic means.

Billing and payment. I understand that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic will inform in advance about the cost of a consultation or treatment and that payment has to take place immediately following the consultation or treatment by credit card, debit card or in cash.

EMERGENCY SITUATIONS

If there is an emergency situation telemedicine is not an appropriate method of care.

IN CASE OF AN EMERGENCY, YOU SHOULD CONTACT YOUR LOCAL HEALTHCARE PROVIDER OR CALL 911.

I understand that in emergency situations, it may be necessary or advisable for Epione Medical Care Facilities VBA d.b.a. Medcare Clinic to perform services and/or procedures that may not be fully discussed with me (or my parent/guardian) in advance. I consent to these services and/or procedures under those circumstances.

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth and health services offered by Epione Medical Care Facilities VBA d.b.a. Medcare Clinic may also include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Epione Medical Care Facilities VBA d.b.a. Medcare Clinic providers include any and all healthcare providers who are assigned to your telehealth appointment.

Epione Medical Care Facilities VBA d.b.a. Medcare Clinic providers are an addition to, and not a replacement for, your local family doctor/primary care physician. Responsibility for your overall medical care should remain with your local family doctor/primary care physician.

Expected benefits:

– Improved access to care by enabling you to remain in your home/whichever environment you prefer while Epione Medical Care Facilities VBA d.b.a. Medcare Clinic providers consult and obtain test results at distant/other sites.

– More efficient care evaluation and management.

Possible risks:

– Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies:

– My computer, tablet, or phone may not be private and secure, especially if other people use it. It is my responsibility to make sure my internet system is private and secure and to make sure I am in a private place during the visit.

– Technical problems may interrupt or stop the visit before it is done.

– My healthcare provider cannot examine me as closely during a telehealth visit, and this may make it harder to determine what is wrong with me.

– In rare events, Epione Medical Care Facilities VBA d.b.a. Medcare Clinic providers may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telemedicine consult, a meeting with your local family doctor/primary care physician, or something else.

– In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

– In rare events, a lack of access to complete medical records may result in adverse interactions or allergic reactions or other judgment errors.

If you need to contact us for whatever reason, please reach us at contact@medcare-aruba.com

By clicking “I have read, understood, and agree with the Informed Consent for telehealth services and health services,” you acknowledge that you understand and agree with the following:

1. If your health insurance coverage does not pay for the services you receive from Epione Medical Care Facilities VBA d.b.a. Medcare Clinic in full, you may be fully or partially responsible for payment.
2. I hereby consent to receiving Epione Medical Care Facilities VBA d.b.a. Medcare Clinic’s telehealth services and health services via the technologies it has available. I understand that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my local family doctor/primary care doctor. I also understand it is up to the Epione Medical Care Facilities VBA d.b.a. Medcare Clinic provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
3. I understand that the Epione Medical Care Facilities VBA d.b.a. Medcare Clinic provider will take responsibility for my care only after I have answered all the required health questions, made payment, and/or had an audio/video call with the Epione Medical Care Facilities VBA d.b.a. Medcare Clinic provider and the Epione Medical Care Facilities VBA d.b.a. Medcare Clinic provider has subsequently received my request for treatment and my responses to all the required health questions and any photos and/or information received from an audio/video chat, reviewed all my information, and then subsequently determined that I am a good candidate for the telemedicine services. I understand that the provider’s duty of care does not begin at the point of me answering questions or making payment or starting an audio/video call but at the point at which the provider accepts the duty of care.
4. I understand that making a request for treatment (by completing a telehealth appointment and making payment, including providing photos and/or initiating an audio/video chat) or sending a message through the website or through other means does not in and of itself create a duty of care or create a provider-patient relationship.
5. I understand that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of the Dutch Caribbean islands.
6. I understand there is a risk of technical failures during the telemedicine encounter beyond the control of Epione Medical Care Facilities VBA d.b.a. Medcare Clinic. I agree to hold harmless Epione Medical Care Facilities VBA d.b.a. Medcare Clinic for delays in evaluation or for information lost due to such technical failures.
7. I understand that I have the right to withhold or withdraw my consent to the use of telehealth services and health services in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services and health services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I will be directed to contact my local healthcare provider immediately and that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic providers are not able to connect me directly to any local emergency services.
8. I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests or healthchecks may be conducted by individuals at my location, or at Epione Medical Care Facilities VBA d.b.a. Medcare Clinic’s clinic, or at a testing facility, or at a lab, at the direction of the Epione Medical Care Facilities VBA d.b.a. Medcare Clinic provider (e.g. labs, healthchecks or bloodwork).
9. I understand that I may expect the anticipated benefits from the use of telehealth in my care but that no results can be guaranteed or assured.
10. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Epione Medical Care Facilities VBA d.b.a. Medcare Clinic provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
11. I understand that there is no guarantee that I will be given a prescription at all.
12. I understand that if I participate in a telemedicine consultation that I have the right to request a copy of my medical records which will be provided to me by Epione Medical Care Facilities VBA d.b.a. Medcare Clinic at reasonable cost of preparation, shipping, and delivery.
13. I understand that Epione Medical Care Facilities VBA d.b.a. Medcare Clinic can contact me on voice or text messaging services (e.g. email, voicemail, phonecall, sms, WhatsApp, Zoom or other applications for communication) to inform me about details about my next appointment (provider name, date/time, and callback number), test an dother exam results, account payments, balnaces, or cost estimates.

EMERGENCY SITUATIONS

If there is an emergency situation telemedicine is not an appropriate method of care.

IN CASE OF AN EMERGENCY, YOU SHOULD CONTACT YOUR LOCAL HEALTHCARE PROVIDER OR CALL 911. 

 

Translation

Our Informed consent was originally written in English (US). We may translate it into other languages.

In the event of a conflict between a translated version of our Informed consent and the English version, the English version will control.

 

INDEMNIFICATION

YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PROVIDER, ITS EMPLOYEES, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS OR DAMAGE, INCLUDING ANY AND ALL INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, OR EXEMPLARY DAMAGES, EXPENSES, LIABILITIES, CLAIMS, OR DEMANDS WHATSOEVER ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE, WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO THE PROVIDER’S NEGLIGENCE.

Contact details

Epione Medical Care Facilities VBA d.b.a. Medcare Clinic

Avicenastraat 16, Oranjestad

Aruba

contact@medcare-aruba.com