Ask Hoag - Consent to Treatment and Conditions of Treatment

Hoag Clinic – Ask Hoag – Consent to Treatment and Conditions of Treatment

Name: [LAST] [FIRST] [MIDDLE]

Date of Birth: [INSERT]

Consent to Treatment

I hereby consent to all health care treatment and procedures provided by Hoag Clinic, its physicians, clinicians, and other personnel. Such treatment and procedures may include diagnostic, therapeutic, imaging, and laboratory services.

I understand that the licensed health care provider primarily responsible for my care may obtain input or advice from other physicians, clinicians, or health care personnel regarding my care. I acknowledge that any such consulting provider will be acting solely in a consultative capacity, is not my treating provider, and I do not have a provider-patient relationship with any consulting provider. Any decisions regarding my health care treatment and procedures, including how to use any consultative input, will be made by the licensed health care provider directly involved in furnishing my care.

Consent to Telehealth Services and the Use of AI Technologies

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a health care provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care.

There are some benefits of receiving health care services through telehealth, such as improved access to care, and convenience. There are also some limitations to receiving health care services through telehealth. The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination. Similarly, there are risks associated with participating in telehealth, including a risk of technical failures during the telehealth visit beyond the control of Hoag Clinic.

I understand that Hoag Clinic may use automated technologies, including generative artificial intelligence (“AI”) technologies (collectively, the “AI Technologies”), to assist with patient intake, symptom collection, care coordination, visit routing, and documentation. The AI Technologies help organize and summarize information I provide. I further understand that, in connection with telehealth visits conducted through the platform, Clinic may use the AI Technologies to automatically transcribe audio and/or video communications and to generate summaries, draft documentation, and patient care plans or after-visit materials based on those communications. The AI Technologies do not independently diagnose medical conditions or determine treatment, and a licensed health care provider will review relevant information and make all final clinical decisions. Information I provide through the AI Technologies may be used to create summaries or other documentation for my medical record.

I understand that outputs generated by the AI Technologies are based solely on the information I provide and may be incomplete or inaccurate. The effectiveness of the AI Technologies depends on the accuracy and completeness of the information I submit and the quality of the telehealth connection and communications during the visit. I further understand that technical issues, system errors, connectivity failures, or interruptions may occur and could delay review or response.

Our telehealth providers do not address medical emergencies, and the telehealth platform is not continuously monitored. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

Hoag Clinic may also use information generated through the AI Technologies, in accordance with applicable law, to support quality improvement, care coordination, and related health care operations, including evaluation and improvement of the AI Technologies and related services.

Financial Responsibility

I hereby assign and authorize direct payment to Hoag Clinic any insurance benefits otherwise payable to me or on my behalf for the services rendered. It is agreed that payment to Hoag Clinic, pursuant to this authorization, by an insurance company shall discharge the insurance company of any and all obligations under a policy to the extent of such payment. I understand that I am financially responsible for charges not paid according to this assignment. I hereby attest that the insurance information provided to Hoag Clinic is accurate, and that I am an eligible member. I understand that I am responsible for knowing my benefits/coverage and acknowledge that tests ordered by my physician may NOT be covered by my insurance company.

I understand that I will be charged a 1% per month finance charge on all accounts over 90 days. I hereby authorize the release of all information to other physicians and insurance carriers for the purpose of payment for medical services, and further treatment of care by another physician. I further agree that a photocopy of this form shall be as valid as the original.

Payment is due at the time services are rendered. All charges are my direct responsibility. Hoag Clinic cannot render medical services on the assumption that charges will be paid by my insurance company. If Hoag Clinic has problems collecting payments from me, Hoag Clinic will also add attorney’s fees, collection agency costs and any related fees to my bill.

Patient Portal

Hoag Clinic utilizes a Patient Portal, which allows me to electronically access my medical information. By click-signing this form, I hereby request and agree that my medical information and laboratory test results may be provided to the Patient Portal, so that I may access them electronically as part of my clinical health record. I understand that summaries of information I provide through the AI Technologies, including summaries generated from telehealth visits, patient care plans, and after-visit materials, may also be included in my medical record and made available through the Patient Portal. I understand that, unless certain conditions are satisfied, the laboratory test results made available through the Patient Portal will not include test results for HIV, hepatitis, drug abuse, or routinely processed tissues.

Communication Consent

By providing my cell, landline, or any other phone numbers, I expressly consent to receiving communications from Hoag Clinic, staff, contractors, collection agents, and others, at any number I provide or that are later acquired for me. These parties may use this information to contact me by live agent, voice mail, text message, using an auto-dialer or other computer assisted technology, pre-recorded message(s), or by any other form of electronic communication for any purpose, including but not limited to, appointment and follow-up health care reminders, scheduling, my account(s), providing feedback on Hoag Clinic services, assignment of benefits, and/or financial responsibility. I understand that depending on my phone plan, I could be charged for these calls or text messages. I further understand that I can opt out of receiving text messages at any time by replying “STOP” from my mobile device. I agree to provide new number(s) if my number(s) change. Providing these numbers is not a condition of receiving health care services.

Health Information Exchange

Hoag Clinic may participate in one or more health information exchanges (HIEs) and may electronically share your medical information for treatment, payment and health care operations purposes with other participants in the HIEs. HIEs allow your health care providers to efficiently access and use medical information necessary for your treatment and other lawful purposes. The inclusion of your medical information in an HIE is voluntary and subject to your right to opt-out. If you do not opt-out of this exchange of information, we may provide your medical information in accordance with applicable law to the HIEs in which we participate. You can choose not to have your information shared through any of our HIE networks (that is, “opt out”) at any time. You may do this by contacting the Hoag Health Information Management Department at (949) 764-8326, Option 5 or HoagMedicalRecords@hoag.org.

Parental Responsibilities for Minor Patients (Ages 12 to 17)

The following terms apply when the patient is between 12 and 17 years of age (the “Minor”):

A parent or legal guardian (“Parent”) must authorize diagnostic and therapeutic treatment for the Minor, be present for and supervise the virtual consultation as required by Hoag Clinic policy, provide accurate health, demographic, and insurance information on the Minor’s behalf, participate in care discussions with the treating Provider unless otherwise restricted by applicable law, and verify they have legal authority to consent to treatment of the Minor.

□ACCEPT. By clicking “Accept”, I acknowledge that I have carefully read, understand, and agree to the terms of this Hoag Clinic – Ask Hoag – Consent to Treatment and Conditions of Treatment form.

Patient’s Name: [INSERT] Date: [INSERT]

Or if signed by other than patient, indicate relationship: [INSERT]

Name (Legal Representative): [INSERT]