My Virtual Physician Consent for Treatment

Attendance at your appointment is considered your consent to these terms and conditions.

HIPAA Privacy and Release of Information Authorization

I hereby authorize My Virtual Physician (DL Howard MD PHD, PLLC) and its affiliates, employees, and agents to use and disclose my protected health information. This information includes, but is not limited to, my diagnosis, treatment, claims payments, health care services, name, address, social security number, and Member ID. The purpose of this authorization is to help me resolve claims and health benefit coverage issues.

I understand that any personal health information released to the person or organization identified above may be subject to re-disclosure by them and may no longer be protected by applicable federal and state privacy laws.

I have the right to revoke this authorization at any time by providing written notice to My Virtual Physician. However, this authorization may not be revoked if the practice, its employees, or agents have already taken action based on this authorization before receiving my written notice. I also have the right to receive a copy of this authorization.

I understand that information used or disclosed as a result of this authorization may be re-disclosed by the recipient and may no longer be protected by federal or state law.

I further understand that this authorization is voluntary and I may refuse to sign it. My refusal to sign will not affect my eligibility for benefits, enrollment, or payment for or coverage of services.

I have been advised of My Virtual Physician’s Privacy Practices, Release of Billing Information policy, Assignment of Benefits policy, and I grant the practice Medication History Authority.

Patient Financial Policy

I hereby authorize My Virtual Physician to treat me and to furnish information to insurance carriers concerning my diagnosis and treatment. I understand that I am responsible for all charges, regardless of insurance coverage. I also understand that payment (including self-pay, co-pays, and deductibles) is due at the time of service.

I understand that charges are not final until my chart has been reviewed and the billing process is completed. If a final balance results in a credit, My Virtual Physician has 30 days to notify me by phone or email. If there is no response to the notification, I authorize the credit to remain on my account and be applied to any future services.

I authorize my insurance company to pay benefits directly to My Virtual Physician (DL Howard MD PHD, PLLC). I have read, understand, and agree to the My Virtual Physician Patient Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility.

I understand that if I do not pay for services as they are rendered, a service charge may be added each month to any outstanding balance. If my account becomes delinquent, I understand that I am responsible for any and all legal fees, court costs, and collection fees that result from collection activity.

Informed Consent

I voluntarily consent to and authorize My Virtual Physician as my medical provider. I agree that the physicians, their assistants, or designees (collectively “the physicians”) may provide any care they deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology, laboratory procedures, administration of routine drugs, biologicals, and other therapeutics, as well as routine medical and nursing care. I authorize my physician(s) to perform additional or extended services in emergency situations if necessary to preserve my life or health. I understand that my care is directed by my physician(s) and that other personnel will provide care and services to me according to their instructions.

I acknowledge that no guarantees or promises have been made to me regarding the results of any diagnostic procedure or treatment.

I am aware that I may stop treatment at any time.

I am aware that if I am paying for services “out of pocket,” I am responsible for all balances due.

I agree that I have been fully oriented to the treatment being provided to me. I have reviewed my rights and responsibilities as a client and am aware of the grievance process and the discharge/termination policy of this agency.

Telehealth Treatment Consent Form

I agree to receive medical and/or behavioral health treatment through telehealth services from My Virtual Physician. I understand and accept the following terms:

Telehealth involves the use of secure electronic communication to deliver healthcare services remotely.
Providers involved in my care may include physicians, nurse practitioners, behavioral health clinicians, and other licensed professionals.
I understand that I may be required to share personal medical information over electronic systems.
I acknowledge that telehealth sessions may include video, audio, medical images, and/or health data exchange.
I understand that there are potential risks to using telehealth, including technical difficulties, data breaches, or limited provider access to physical findings.
I understand that all confidentiality protections under federal and state law apply to telehealth services provided by My Virtual Physician.
I am aware that I may stop or decline telehealth treatment at any time and request in-person care if available.
I understand that not all conditions are appropriate for telehealth and that my provider may require in-person follow-up if needed.

I consent to receive medical or behavioral health treatment via telehealth and authorize the provider(s) at My Virtual Physician to use and disclose health information as needed to provide services.