Supplemental Consent to Virtual Care Consent Form for HHC 24/7 Services

Virtual Care Consent Form 

Virtual care (also known as “telehealth” or “telemedicine”) is the use of secure electronic communications, information technology, or another communication method between you and your Provider at different locations. Virtual care services are offered by Hartford HealthCare and its affiliated entities (“HHC”) and providers (your “Provider”), and may include patient consultation, diagnosis, treatment recommendation, prescription, or a referral to in-person care, as determined appropriate by your Provider. 

Potential Benefits: You may benefit from virtual care services, but results cannot be guaranteed. Potential benefits include easier access to care and the convenience of meeting with your Provider from a location of your choosing. 

Potential Risks: There are some risks of virtual care, including, but not limited to: 

  • Technological failures such as unclear video, loss of sound, poor internet connection or loss of internet connection. If any of these risks occur, the virtual encounter might need to be stopped.
  • In rare events, security protocols could fail, causing a breach of privacy of medical information; 
  • Though unlikely, delays in evaluation and treatment could occur due to deficiencies, disruptions or failures of the equipment or technology.

Service Limitations: Virtual care may not be the most effective form of treatment for certain individuals or health concerns. Your Provider may determine that you would be better served by a face-to-face visit, in which case you may be asked to schedule an in-person appointment.

Privacy. The laws that protect the privacy and confidentiality of your health information also apply to virtual care services. Virtual care services are provided through a HIPAA-compliant platform. HHC does not control the devices or computers or the internet over which you may choose to provide your confidential or personal information and therefore cannot prevent interceptions or compromises to your information while in transit to HHC. Upon your request, your Provider must disclose the records from your virtual care encounter to your primary care provider.

Revocation. Your participation in virtual care services is voluntary. You may refuse to participate or decide to stop participation at any time without affecting your rights to future care or treatment. Notify your Provider if you wish to revoke consent to receive virtual care services. 

By using HHC 24/7 virtual care services, I agree to the following additional terms, which supplement my Virtual Care Consent Form:   

  1. I understand that the  telehealth services should not be utilized in a medical emergency and that I should seek immediate in-person medical attention by calling 911 (or the local emergency number) or going to the nearest emergency room.
  2. I am at least 18 years of age.
  3. I agree and represent that due to state medical licensure laws I will use the telehealth services only when I  am physically located in Connecticut, Massachusetts, New York and Rhode Island,  and that I will notify my HHC 24/7 provider immediately if I am no longer located at the time of telehealth visit in the state I  selected as my location on the telehealth platform.
  4. I understand that when receiving telehealth services, I may be required to upload a copy of my identification card (e.g., drivers’ license, state ID) and a self-photograph (“selfie”) for verification purposes, location purposes, and evaluation and treatment purposes. I also understand and agree that as part of the verification process, Hartford Healthcare’s  vendors may utilize biometric measurements and analysis to compare and verify the image obtained from my ID and selfie. Such biometrics measurements will be deleted once they are no longer required.  
  5. I understand that that in receiving treatment via telehealth, I will not have an in-person physical examination from the treating provider that might identify a potentially serious medical condition, and that the absence of an in-person physical examination may affect the provider’s ability to diagnose any potential condition, disease, or injury or to prescribe certain medications. I also understand that  that additional diagnostic exams, blood tests, or other procedures may be needed to evaluate or treat my medical condition.
  6. I understand that the HHC 24/7 providers do not prescribe U.S. Drug Enforcement Administration/DEA controlled substances, such as those containing opioids.  Providers reserve the right to deny care for actual or potential misuse of the telehealth services.
  7. I understand that as part of my HHC 24/7 telehealth visit, I may not be able to select a specific provider.  
  8. I understand that the telehealth care I receive is based on the symptoms and other information I provide or upload to the HHC 24/7 telehealth platform. This includes information provided through the chatbot (or other AI-powered tools), text messages, digital photos, audio, video, other data transmissions, or directly  to my HHC 24/7 provider(s) and care team. I understand that my telehealth providers will rely on this information to provide care and that such information and interactions may be recorded and become part of my medical record.
  9. I understand that artificial intelligence (AI) including generative AI based tools may be used to support the HHC 24/7 telehealth visits and interactions, e.g., to create medical notes, update the medical record and provide the patient and the provider with information on potential diagnoses and treatment plans.  These tools are an aid to the patient and the care team, but ultimately the provider will make a clinical decision using their own professional judgment.  I understand that information I provide in connection with these tools is stored in compliance with HIPAA regulations and may be used to improve the  technology and AI-based tools. I understand that if I do not consent to this telehealth visit using AI technology, the Hartford Healthcare staff can assist with scheduling an in-person visit.

By beginning my HHC 24/7 telehealth visit, I confirm that I have read and understand the information in this document and  I agree to the above conditions.