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Consent Form



MyConsult Online Medical Second Opinion - Consent Form
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
 
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