Virtual Visit Hippa Form

I understand that my health care provider may engage in a virtual/telemedicine visit with me. 2. My health care provider has explained to me how the video conferencing technology will be used to affect 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. 3. 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 virtual/telemedicine visit if it is felt that the videoconferencing connections are not adequate for the situation. 4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the visit other than my health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the visit and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the virtual/telemedicine examination room: and or (3) terminate the consultation at any time. 5. I have had the alternatives to a virtual/telemedicine visit explained to me, and in choosing to participate in a virtual/telemedicine visit. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider. 6. In an emergent visit, I understand that the responsibility of the virtual/telemedicine staff is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection. 7. I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented. 8. I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. 9. I hereby acknowledge that I will incur a $50 fee for NO CALL/NO SHOW appointment (Non-Medicaid patients). I also acknowledge that if I cannot make my scheduled appointment, I will inform SOL Medical Group staff 48 hours before my appointment. By signing this form, I certify: That I have read or had this form read and/or had this form explained to me and that I fully understand its contents including the risks and benefits of the procedure(s).
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Controlled Substance Agreement

I Understand that my provider is prescribing a controlled substance medication as part of my treatment plan. This controlled substance agreement (“Agreement”) is a tool for communication allowing us to work together in good faith and for you to understand the importance of this medication. In prescribing a controlled substance medication, we must partner with our patients to create the best treatment plan for your improvement and/or management of care. This requires cooperation, trust, and mutual respect. If you cannot agree with the following terms, we will be unable to prescribe controlled substance medication and the failure to continue to follow all terms will result in discontinuing the controlled medication and/or dismissal from our practice. Please read the following as part of the controlled substance agreement: 1- I agree to take any controlled substance EXACTLY as instructed. I am NOT allowed to change the dose or number of times per day that I take my medication without FIRST talking to my Provider. 2- I agree to safekeeping my controlled substance medication prescriptions and medication. I understand that lost, misplaced, or stolen prescriptions or medications will NOT be replaced. 3- I agree and understand that my provider reserves the right to obtain random or unannounced prescription drug testing. The drug testing will be required at a minimum of the onset of the prescription and every 3-6 months thereafter depending upon the medication and dosage. If I fail to provide the sample when asked or if the results are inconsistent, I may forfeit the right to continue receiving care and or controlled medications.¬¬¬ 4- I will keep regularly scheduled appointments with my provider at SOL Medical Group. There may be times when your medication will need a refill between office visits. If that occurs, please call our staff at least 2 days before your medication runs out. 5- I agree to tell my provider about all other medications and treatments I am receiving. I will not request or accept controlled substances/medications from any other provider or individual without talking about it with my SOL Medical Group provider while I am receiving a controlled substance medication from SOL Medical Group. 6- I agree to use one pharmacy for my controlled substance medications. The provider will add that one pharmacy to your chart. I agree to notify the provider as soon as possible with any concerns regarding pharmacies. 7- You agree to allow your provider to contact any healthcare professional, family member, pharmacy, legal authority, or regulatory to obtain or provide information about your care or actions, if the provider feels it is necessary. I have read this agreement. I fully understand the consequences of violating this agreement may include being discharged from this practice.
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