Telehealth Consent Form – Open Cities Health Center

Eye Care Provider Referral Form

"*" indicates required fields

Name*

First Last

Phone*

Address

Street Address City State ZIP Code

Birth Date*

Date Electronically Signed*

By checking the box below, I understand and agree to the following statement:*

The laws that protect privacy and confidentiality of medical information also applies to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to other entities without my consent. No one will record the session, including you or the provider, without permission from both parties. Recording used for training will require written consent. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment. There are potential benefits and risks of video-conferencing that differ from in-person appointments that may limit the type of services that can be offered to my healthcare (e.g., including insufficient video imaging/resolution, inability to take labs/temperature, etc.). I agree to use the video-conferencing platform selected for our virtual appointment, and clinic staff will assist me in understanding how to use it. A webcam or a smartphone will be used. It is important to use a secure internet connection rather than public/free Wi-Fi, and to be in a quiet, private space free of distractions in a well-lit room. We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation. Telehealth services are submitted to my insurance like any other health service; however, if the service is not reimbursed, I am responsible for full payment. My provider may determine that due to certain circumstances, telehealth is no longer appropriate and that we should resume our appointments in-person or by other means to get health needs met. This document is effective for 1 year of signing.

Open Cities Health Center

We’re here to help you live your healthiest, happiest life.

Dunlap Clinic

409 North Dunlap St.
St. Paul, MN 55104

HOURS
MWTHF: 8am – 5pm
Tuesdays: 8am – 8pm

North End Clinic

916 Rice St.
St. Paul, MN 55117

HOURS
Monday – Friday: 8am – 5pm

Health Services

About Us

Open Cities Health Center is a FTCA deemed Facility.

This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.