Virtual Video Consultation Consent

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VIDEO CONSULTATION CONSENT FORM

At Givens Facial Plastic Surgery, we have patients who travel both nationally and internationally to have their surgery performed by Dr. Givens in Austin. We understand the need to accommodate these patients and make their experience as pleasant and comfortable as possible. Initial consultation via video and virtual internet-based means is offered to patients prior to their long-distance travel to the office and surgical appointment.

Prior to your virtual video consultation, it is important that you understand the benefits and risks of virtual consultation provided by Dr. Givens.

Initial

I understand that during my virtual video consultation Dr. Givens will evaluate my concerns based upon the information provided by me, my pre-filled patient paperwork, and the images seen through video conference. I understand that the virtual video evaluation is NOT a means of true medical examination and that no specific diagnosis or medical advice can be given until an in-person, real-time consultation is performed.

I understand that Dr. Givens will provide general information and education about possible procedures. Initial However, an in-person consultation will be necessary prior to making final determinations for surgery. I
understand that the procedure or procedures discussed may change once I have been evaluated in person.

Initial

I understand that a virtual video consultation is not a substitute for a medical exam. If I have any urgent concerns, Dr. Givens recommends that I seek medical attention immediately for local hospital/Emergency Department. I understand that no prescriptions can be provided to patients without an in-person office evaluation.

Initial

I understand that the risks involved with virtual video conference include the potential release of private information due to the complexities and abnormalities involved with the Internet. Viruses, Trojans, and other involuntary intrusions have the ability to grab and release information I may desire to keep private. Furthermore, there is the risk of being overhead by anyone near me if I do not place myself in a private area away from another's intrusion. It is my responsibility to create an environment on my end that is not subject to unexpected or unauthorized intrusion of my personal information. It is the responsibility of Givens Facial Plastic Surgery to do the same.

Initial

I understand that some virtual video consultation software and programs including but not limited to FaceTime and Skype have not declared Health Insurance Portability and Accountability Act (HIPAA) compliance or signed a Business Associate Agreement (BAA)--a necessary requirement for HIPAA compliance. I understand that this means these virtual video consultation platforms do not disclose security breaches or findings from security audits. Therefore, if I such platforms, I do so knowing that I am using a vendor who has declared that they won't give providers a BAA as mandated by HIPAA.

By signing below, I acknowledge that I understand that even protected internet connections may not be Health Insurance Portability and Accountability Act (HIPAA) compliant. By accepting this method of communication, I waive this right with virtual video consultation but retain the option to withhold or withdraw consent to video conferencing at any time without affecting the right to future care or treatment.

Patient/Guardian Signature:

Date:

Staff Initials:

3939 Bee Caves Rd ¨ Austin TX 78746 ¨ (737) 787 ­ 8200 ¨ office@givensMD.com