Kenneth Stark, MD, PA
I hereby voluntarily consent to receive "virtual" care.I understand that this consent form will be valid and remain in effect as long as I receive medical care with Dr. Kenneth Stark."Virtual visits" mean that you may be evaluated and treated by a health care provider or specialist from a distant location via electronic communication. Since this may be different than the type of consultation with which you are familiar, it is important you understand and agree to the following statements:
Your treating provider will be at a different location from you. Additional medical or registration personnel may also be present in the room with the provider. I understand there are potential risks to the technology, including but not limited to, interruptions, unauthorized access, technical difficulties, and call termination. I understand there are alternatives and limitations to this type of care. I understand that my healthcare provider or I can discontinue the telemedicine consultation if it is felt that the videoconferencing connections are not adequate for my situation. I understand that I may be disconnected before all my medical problems are know or treated and it is my responsibility to make such conditions or symptoms known to the medical personnel as well as make arrangements for follow up care. I understand that standard deductibles and coinsurance amounts apply to these "Virtual Visits" and I consent to Virtual Treatment.
By checking this box I acknowledge that I have read all of the above statements and fully understand this Consent for Non-Face-to-Face "Virtual" Visits and agree to its contents
