Consent to Telehealth Services

Consent to Telehealth Services and Riz Eye Care Policies

This form describes Riz Eye Cares Telehealth treatment alongside a Physician Assistant, payment policies and includes:

Your consent to receive medical treatment from Riz Eye Care (and your other rights and responsibilities);
Your agreement to receive services using telehealth technology along side a credentialed Physicians Assistant ; and
Your agreement to pay in full any charges that are your responsibility.

I understand and agree that I am signing this Consent electronically and that (i) I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services, and (ii) I agree to the remaining terms of this Consent, including the terms of Riz Eye Care’s Privacy Notice described below.

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.

By accepting to receive treatment at Riz Eye Carel, I agree to receive telehealth services and be assessed by a Physicians Assistant. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications along side our Physicians Assistant. During my visit, I have the option to visit with a State Licensed Optometrist and I will be able to see and speak with each other from remote locations.
I understand and agree that:
- I will not be in the same location or room as my medical provider.
- Riz Eye Care is licensed in the state in which I am receiving services. I will report my location accurately during online registration.
- Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to Riz Eye Cares provider’s office; (ii) more efficient medical evaluation and management; (iii) opportunity to visit any of Riz Eye Cares locations and still receive the same medical evaluation with a lead Optometrist, (iiii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
- Potential limitations of telehealth include: (i) limited or no availability of diagnostic 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 resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Riz Eye Care responsible for lost information due to technological failures.
- I further understand that Riz Eye Cares 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 Riz Eye Care relies on information provided by me before and during our telehealth/ aided encounter and that I must provide information about my medical history, condition(s), and current or previous medical care/ ocular health that is complete and accurate to the best of my ability.
- I may discuss these risks and benefits with my provider at Riz Eye Care and will be given an opportunity to ask questions about telehealth services. I reserve the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to receive future treatment by Riz Eye Care and their providers.
- I understand that the level of care provided by my Eye Care Specialist 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 Riz Eye Care clinic, hospital emergency department or other appropriate health care provider.
- I have the right to receive face-to-face medical services at any time by traveling to a Riz Eye Care Clinic that is convenient to me.
- In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
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.
- Riz Eye Care will provide care consistent with the current standards of medical practice but makes no assurances or guarantees as to the results of treatment.
- I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Riz Eye Cares 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.

HIPAA (“Privacy Notice”)

Riz Eye Care will protect the privacy of my health information and will not use or disclose it except as permitted by law. Patient First’s privacy policies are more fully described in the Privacy Notice, which is available for review and download here: www.rizeye.com. By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to Patient First’s use and disclosure of my health information in accordance with its terms. I understand that all existing confidentiality protections that apply to in-person treatment apply to telehealth services and services rendered by out Physician Assistant.

Payment Policy

I acknowledge, understand and agree that:

It is my responsibility to determine whether Riz Eye Care services are covered by my insurer. I will pay the cost of any service that is not covered by my health plan for any reason or are covered but applied to a deductible.
I will pay at time of service any required co-payments, co-insurance and deductibles, as well as charges for services not covered by insurance, outstanding balances and delinquent accounts.
I assign Riz Eye Care all health care benefits to which I am entitled under any insurance policy or benefit plan and authorize payment of benefits directly to Riz Eye Care.
If I have health care benefits, Riz Eye Care will submit a claim to my insurer and allow 90 days for reimbursment. If my insurer does not respond within 90 days, Riz Eye Care will assume that the visit is not covered and will, to the extent permitted by law, bill me for the visit charges.
By providing my credit card information and receiving telehealth services, I (i) authorize Riz Eye Care to charge my credit card for any and all unpaid amounts that my insurer determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that Riz Eye Care may charge my credit card for such amounts before my telehealth visit or after my visit with the Physicians Assistant.
I will be billed for all unpaid balances deemed by Riz Eye Care or my insurer to be my responsibility and agree to pay such amounts in full.
Riz Eye Care may charge a fee for medical records. The fee will not exceed $25.00
Riz Eye Care reserves the right to deny services if my account is delinquent.

I understand that I may access and print a copy of this Consent here: www.rizeye.com