Virtual Visit Setup Instructions

Virtual Visit Program

Service Agreement and Notice of Coverage

I. Notice of Coverage

Your health insurance plan has established rules for the payment of health care services. Visits offered through the Brigham and Women’s Hospital Physician’s Organization (BWPO) Virtual Visit Program may be subject to co-payment, deductible, and co-insurance based on your insurance benefi ts plan. Policies regarding payment for any BWPO virtual visits can change. Patients will be notifi ed in writing of any changes in coverage and given the chance to withdraw from the Virtual Visit Program at any time.

Patient Agreement:

I have been told by my physician or designee that my insurance or worker’s compensation plan may provide payment for the services identifi ed above. I understand that I have the right to decide whether to receive these services. I am also aware that the videoconference technology in use is secure, reliable and reputable, but may have occasional connection issues. I have decided to receive the services, and agree to be personally and fully responsible for necessary electronic equipment for the BWPO Virtual Visit Program.

II. Service Agreement

Brigham and Women’s clinicians will provide the following services:

Video Visits

I understand I am free to withdraw from the BWPO Virtual Visit Program at any time.

Patient Consent

I understand that my health care could be improved by talking with my BWH clinician using electronic media via a virtual visit. My clinician has talked with me about the benefi ts and risks of virtual visits to supplement my care. I understand that a signed copy of this agreement form will be placed in my health record.

The clinician may provide care through following electronic media: video, telephone, email, and text message.

Benefits

Staying in touch with my clinician is important. Virtual visits will allow me to communicate with my clinician from my home, work or other locations. We will use the online format(s) circled above. Therefore, I will not need to travel to my clinician’s offi ce to participate in the Virtual Visit Program. However, I will still need to go to in-person appointments as needed as directed by my physician.

Risks

Federal law requires that health care clinicians protect the privacy and security of my health information. This information is called Protected Health Information (PHI). I understand that my clinician will take all necessary steps to protect the privacy and security of my PHI. However, I understand that as with any electronic transmission, the privacy and security of my PHI cannot be guaranteed. I also understand that I should conduct my virtual visit in a private and secure place, so that others cannot see or hear my PHI discussed.

Important Information

I understand that a virtual visit does not replace the in-person relationship between me and my clinician. I am responsible for calling my clinician if I have any questions or concerns about my health in between virtual visits. I understand that if I have a medical emergency, I should call 911 right away.

By typing your name and DOB below, I acknowledge that I have read and agree to being bound by the above Patient Agreement. By typing your name and DOB below, I acknowledge having read, and agree to being bound by, the terms of this Service Agreement. By typing your name and DOB below, I agree to use the Virtual Visit Program as specified by my clinician.