MyConsult Online Medical Second Opinion Consultation Patient Consent Form
|
Cleveland Clinic Consent for the Provision
of Certain Medical Services over the Internet and Authorization for the Release of Medical Information |
Section 1: Consent for the Provision of Certain
Medical Services Over the Internet:
|
Patient Information |
Name: | _________________________________ |
Address: | _________________________________ |
| _________________________________ |
| _________________________________ |
Date of Birth: | _________________________________ |
Home Phone: | _________________________________ |
|
|
This Web site is designed to permit you to seek an opinion from a physician on the staff of
Cleveland Clinic ("CC"). To request an online medical second opinion evaluation, you must certify by
checking both boxes below that you are 18 years of age or older and are under the current care of a physician.
|
|
 |
I am 18 years or older. |
 |
I am under the care of a physician |
|
|
The service provided through this Web site
is different from the diagnostic services typically provided by a physician. The CC physician providing this service
will not have the benefit of information that would be obtained by examining you in person and observing your physical
condition. Therefore, the physician may not be aware of facts or information that would affect his or her opinion.
In some cases, these facts may be critical to the opinion. By deciding to request this service, you acknowledge that
you are aware of this limitation and agree to assume the risk of this limitation. |
|
Please read the following and indicate agreement to each paragraph by checking the "I agree" box below that paragraph: |
|
I UNDERSTAND THAT THE ONLINE MEDICAL SECOND OPINION EVALUATION THAT I RECEIVE IS LIMITED AND
PROVISIONAL. I UNDERSTAND THAT IT IS NOT INTENDED TO REPLACE A FULL MEDICAL EVALUATION OR A FACE-TO-FACE
VISIT WITH A PHYSICIAN. I UNDERSTAND THAT THE INTERNET PHYSICIAN DOES NOT HAVE IMPORTANT INFORMATION THAT
IS USUALLY OBTAINED THROUGH A PHYSICAL EXAMINATION. I UNDERSTAND THAT THE ABSENCE OF A PHYSICAL
EXAMINATION WILL AFFECT THE PHYSICIAN'S ABILITY TO DIAGNOSE ANY CONDITION, DISEASE OR INJURY. I
UNDERSTAND THAT BY PARTICIPATING IN THIS SERVICE I AGREE TO SOLELY ASSUME THE RISK OF THIS LIMITATION. I
UNDERSTAND THAT NO WARRANTY OR GUARANTEE HAS BEEN MADE TO ME CONCERNING ANY PARTICULAR RESULT OR CURE OF
ANY CONDITION. I ALSO UNDERSTAND THAT THE CONFIDENTIALITY OF MEDICAL INFORMATION MAY BE COMPROMISED BY
ELECTRONIC TRANSMISSION. I HAVE READ AND AGREE TO BE BOUND BY THE TERMS AND CONDITIONS OF USE OF USE SET FORTH ON THIS WEB SITE.
|
|
Yes, I agree |
No, I do not agree |
|
|
I ACKNOWLEDGE THAT I HAVE RECEIVED THE NOTICE OF PRIVACY PRACTICES OF THE CLEVELAND CLINIC HEALTH
SYSTEM (CCHS). I UNDERSTAND THAT THE NOTICE OF PRIVACY PRACTICES EXPLAINS HOW CCHS MAY USE AND DISCLOSE
CONFIDENTIAL HEALTH INFORMATION THAT IDENTIFIES ME. I CONSENT TO LET CCHS USE AND DISCLOSE HEALTH
INFORMATION ABOUT THE ONLINE MEDICAL SECOND OPINION EVALUATION. I CAN REVOKE MY CONSENT IN WRITING AT ANY
TIME EXCEPT TO THE EXTENT THAT CCHS HAS ALREADY RELIED ON MY CONSENT. |
|
Yes, I agree |
No, I do not agree |
|
|
|
Section 2: Authorization to Release Medical
Information |
|
If you would like us to share information with
your physician, you must authorize us to do so by providing your physician's name and address and then signing below.
Note: Where we can only provide an online medical second opinion if requested to do so by your physician, he or she must sign the
Physician Consultation Request Form, and you must permit us to send the second opinion to your physician.
|
|
IN ORDER TO PROVIDE THE PHYSICIAN IDENTIFIED
BELOW WITH INFORMATION, I HEREBY AUTHORIZE CLEVELAND CLINIC TO RELEASE TO THE PHYSICIAN MY ONLINE MEDICAL SECOND OPINION
EVALUATION REPORT. |
Yes, I would like you to send a copy of the online
medical second opinion evaluation to the physician below. |
|
|
|
|
Physician Name: |
____________________________ |
|
Address: |
____________________________ |
|
|
____________________________ |
|
|
____________________________ |
|
|
|
I understand that if I do not sign this authorization below the Cleveland Clinic will not be able
to provide me with an online medical second opinion evaluation. I also understand that any disclosure that
the Cleveland Clinic makes to a third party, such as the physician identified above, may or may not be
protected by privacy laws. |
|
This authorization is subject to revocation at any time, except to the extent that action has
been taken thereon, and this authorization will expire one year from the date of authorization written below. |
|
|
_________________________ |
/ |
_________________________ |
|
_____ |
/ |
_____ |
/ |
_____ |
Signature of Patient** |
|
Printed Name |
|
Date Signed |
|
|
COMPLETE THIS FORM AND FAX TO: 1.216.445.6911
|
|
**Form must be printed and signed in ink. E-signatures cannot be accepted.
If other than patient's signature, a copy of legal papers verifying authority (e.g., Power of Attorney, Legal
Guardian) MUST accompany the authorization when presented. The form must be signed, dated, witnessed by two people, and notarized when possible.
|
|
Exception: parent is signing for patient under 18.
|
|
|
If you have questions, please contact the Cleveland Clinic MyConsult Clinical Operations Center: |
|
|
Phone: |
1.216.444.3223 or 1.800.223.2273 |
|
Fax: |
1.216.445.6911 |
|
Email: |
myconsult@ccf.org |
|
| Cleveland Clinic MyConsult Clinical Operations Center |
| 9500 Euclid Avenue, Desk T-43 |
| Cleveland, OH 44195 USA |
|
|
CONFIDENTIAL Cleveland Clinic © 2017. All Rights Reserved
|