Porter Cares

 CONSENT FOR TREATMENT

 

Consent for Treatment

I hereby agree and give my consent to receive medical treatment and/or services from Porter Cares (“Practice”) or their authorized representatives. I understand that this may include, but is not limited to:

• Medical evaluation and diagnosis
• Physical examination
• Routine diagnostic procedures (e.g., blood pressure, blood draws, urine tests)
• Administration of medications or injections
• Minor procedures or treatments as deemed necessary by the provider

 

I understand that I have the right to refuse any medical treatment or procedure, and that I may discuss any and all medical treatments or procedures with my healthcare provider.

 

I understand that not results can be guaranteed or assured – I may not achieve the anticipated benefits of the treatment and/or services from Practice.

  

Financial Responsibility

I understand that standard charges may apply for services. I am responsible for all applicable copays, deductible amounts (including, if you are a Medicare beneficiary, the 20% copay for Part B services), or other fees outlined in my plan or Practice’s fee schedule.

Notice of Privacy Practices

I acknowledge that I have received a copy of Practice’s Notice of Privacy Practices. I understand that Practice has the right to change its Notice of Privacy Practices from time to time and that I may contact Practice at any time to obtain a current copy of the Notice of Privacy Practices.

 

 

 

 

 

 

 

 

 

 

 

 

 

CONSENT FOR TELEMEDICINE

 

What is Telemedicine?

Some of your visits with your healthcare provider may be through telemedicine, which means using video, phone, or other online tools to connect with your healthcare provider. This allows you to have exams, consultations, and treatment from a different location than your provider.

During these visits, we may discuss your medical history and health information through secure audio and video or secure messaging. We may also use video, audio, and messaging to conduct a virtual physical exam, if needed.

Important: Telemedicine is not for emergencies. If you’re having a medical emergency, call 911 right away.

Why Telemedicine?

With telemedicine, you can get care without needing to travel, wait in a clinic, or expose yourself to others. It makes getting treatment easier and more convenient, even if you’re not close to one of our locations.

Risks and Limitations of Telemedicine

Please read and acknowledge the following risks and limitations of telemedicine:

• Technology Issues: Sometimes, there can be delays or poor video/audio due to internet, software, or equipment issues. If this happens, you can reschedule.
• Privacy Risks: Although we follow strict security measures, there’s a small chance that the technology could be hacked, leading to a privacy breach.
• Health Risks: If you don’t share your complete medical history, including past conditions, treatments, and allergies, then adverse treatment, drug interactions, allergic reactions, illness, injury, or even death may occur.

Telemedicine Consent

If you choose to proceed with your telemedicine visit, you acknowledge and agree that:

• You have the option to refuse a telemedicine visit at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any benefits to which you would otherwise be entitled.
• Telemedicine may involve electronic communication of your personal medical information to remote healthcare practitioners who may be located outside of your state.
• You understand that your telemedicine visit may be with a non-physician provider. 
• You will always tell us your correct physical location during telemedicine visits.

This consent applies to all future telemedicine visits with your healthcare provider. If you want to withdraw your consent, please email us at [email protected]. Withdrawing consent won’t impact your access to future care.