Terms and Conditions
Informed Consent to Telehealth Services
This form describes the Quadrant Eye (QE) Telehealth treatment policies and includes:
• Your consent to receive medical treatment from QE (and your other rights and responsibilities);
• Your agreement to receive services using telehealth technology; and
• Your agreement to pay in full any charges that are your responsibility
If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.
1. By using the QE telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my QE provider and I will be able to see and speak with each other from remote locations.
2. I understand and agree that:
• I will not be in the same location or room as my medical provider.
• My QE provider is licensed in the state in which I am receiving services, or has out-of-state privileges per COVID-19 state waivers. I will report my location accurately during registration.
• Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
• Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold QE responsible for lost information due to technological failures.
• I further understand that my QE Provider’s advice, recommendations, and/or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my QE provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
• I may discuss these risks and benefits with my QE provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to future treatment by Patient First.
• I understand that the level of care provided by my QE provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest ophthalmologist, hospital emergency department or other appropriate health care provider.
• In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
3. I consent to, understand and agree that:
• I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
• QE will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.
• QE will not prescribe opioids, Schedule 2 controlled substances (including stimulant medications used to treat attention deficit disorders), or new prescriptions for benzodiazepines to me during a telehealth visit.
• I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to QE’s standard policies regarding request and receipt of medical records and applicable law.
• The laws of the state in which I am located will apply to my receipt of telehealth services.