Informed Consent for Telehealth Services at Nice Healthcare, LLC


Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for examination, treatment, diagnosis, and/or follow-up, and may include any of the following:

·       Patient medical records

·       Medical images

·       Live two-way audio and video

·       Output data from medical devices and sound and video files

Electronic systems used incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

·       Improved access to medical care by enabling a patient to remain in his or her home, physician’s office or at a remote site while the physician obtains test results and consults from healthcare practitioners at distant sites.

·       More efficient medical evaluation and management.

·       Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

·       Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and/or other healthcare providers.

·       Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.

·       Security protocols could fail, causing a breach of privacy of personal medical information.

By signing this form, I understand the following:

1.     The laws that protect the privacy and confidentiality of medical information also apply to telehealth.

2.     I have the right to inspect all information obtained and recorded in the course of a telehealth interaction, and may receive copies of this information for a reasonable fee.

3.     A variety of alternative methods of medical care may be available to me, and I may choose one or more of these at any time. My healthcare provider has explained the alternatives to my satisfaction.

4.     Telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

5.     It is my duty to inform my healthcare provider of interactions regarding my care that I may have with other healthcare providers.

6.     I may expect the anticipated benefits from the use of telehealth in my care, but no results can be guaranteed or assured.

7.     I have a right to receive a copy of this consent form.

Patient Consent To The Use of Telehealth

I have read and understand the information provided above regarding telehealth, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical care.


Consent to Evaluation and Treatment at Nice Healthcare, LLC


The undersigned consents to performance of medical services by Nice Healthcare, LLC. This may include medical evaluation, procedures and treatment. Such procedures may include, but are not limited to: X-rays, wound repair, blood draw and wart destruction. Treatment modalities might include oral, intramuscular, subcutaneous and inhaled medications and wound repair including bio- occlusive glue. I understand that medical care is not an exact science and that no guarantee or warrantee is being made as to my examination, treatment, result or outcome. We are not an Emergency Room and are unable to provide medical services for life-threatening and/or serious illnesses. If you believe you have a life-threatening and/or serious illness, please call 911 or go directly to an Emergency Room. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. However, I understand that doing so may hinder my treatment and/or medical outcome.


Nurse practitioners are governed by each state's respective boards of nursing.


I agree and consent to the use and disclose of my health information for the purpose of treatment, payment from third party payers, and other healthcare operations, such as the maintenance of medical records, communication of health information with other health professionals who contribute to my care, and quality peer reviews and assessments.


I have received a copy of the Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act.


In the case of my bodily fluid exposure to a healthcare employee, I consent to testing, which may include, but not limited to, HIV or Hepatitis, to determine the presence of any communicable disease for the benefit of the exposed employee. I understand that these test results do not become a part of my medical record.


I grant permission for Nice Healthcare, LLC, to take photographs, should the need arise, for purpose of my treatment during my health evaluation and treatment.


I grant permission for Nice Healthcare, LLC , to send me text messages, emails or leave voicemails on my phone regarding wait times, my appointments, follow up questions, billing questions and attempts to collect payment the need arise.


Agreed upon payment are due at time of service including copays or Non-Included Contract Lab or Imaging fees. We accept credit cards. No cash or checks.  We do not accept insurance or submit billing to insurance.  We cannot guarantee that any services will be qualified for reimbursement through your flexible or health savings account. Always check with your tax advisor.  Should my account be referred to an attorney or collection agency, I agree to pay actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at twelve percent per annum, not to exceed the maximum amount permitted by law.

The undersigned certifies that he/she has read the foregoing, and is the patient, the patient’s legal representative or is duly authorized by the patient as the patient’s agent to execute this Consent to Evaluation and Treatment and to accept its terms.