1. Introduction

This consent form explains the nature of Independent Medical Opinions (IMO) provided via telehealth and outlines your rights, responsibilities, and consent to participate in the process. Telehealth allows healthcare providers to conduct medical evaluations and issue medical opinions remotely through video conferencing, phone calls, or secure messaging platforms. Please review the information below and sign to indicate your consent to participate in telehealth-based IMO services.

2. Purpose of Independent Medical Opinion (IMO)

An independent medical opinion (IMO) is a professional medical evaluation provided for purposes such as:

• VA disability claims or appeals
• Legal or litigation purposes
  
  

The IMO is intended to offer an expert opinion based on your medical history, condition, and documentation, but it does not establish a traditional doctor-patient relationship for ongoing treatment.

3. Telehealth Services

• Technology Used: Your IMO will be conducted using secure, HIPAA-compliant telehealth platforms, such as video conferencing, phone calls, or secure messaging services.
• Service Limitations: Telehealth may have limitations, such as not allowing specific physical exams or diagnostic procedures. In such cases, the provider may recommend additional tests or in-person evaluations.
  
  

4. Risks and Benefits of Telehealth for IMO

• Benefits:
  • Convenient access to expert medical evaluations from any location.
  • Reduced need for travel, especially for those in remote areas.
  • Timely delivery of medical opinions for legal or claims purposes.
• Risks:
  • Technical failures (e.g., poor internet connection) may result in delays or disruptions.
  • The lack of physical examination may limit the provider’s ability to make a comprehensive evaluation, potentially requiring in-person evaluation.
  • Despite secure platforms, there is a minimal risk of a data breach. However, every precaution is taken to ensure confidentiality.

5. Confidentiality and Privacy

• HIPAA Compliance: Your telehealth IMO will be conducted using systems that comply with HIPAA regulations to protect your privacy and personal health information (PHI).
• Disclosure of Information: Your PHI and medical opinion will only be shared with third parties (e.g., legal representatives, insurance companies, Veterans Affairs) with explicit consent or as required by law.
• Recording: Sessions will not be recorded without your written consent.

6. Patient Rights and Responsibilities

• Right to Information: You have the right to ask questions about telehealth procedures and any other concerns you may have about the process.
• Patient Responsibilities:
  • You agree to provide accurate and complete medical records and information.
  • You are responsible for ensuring you have the necessary technology (internet, device, software) to participate in the telehealth evaluation.
  • You will make every effort to conduct the telehealth session in a private and secure location.

7. Billing and Financial Responsibility

• Service Fees: The cost of the IMO telehealth service will be disclosed to you before the consultation. Payment is due when the service is requested.
• Insurance: Independent medical opinions are typically not covered by health insurance. You agree to pay any fees associated with the IMO service, including those not reimbursed by other entities.

8. Emergency Situations

• Telehealth services are not suitable for medical emergencies. In the case of a medical emergency, please call 911 or visit the nearest emergency room. FarmUS Health Services does not offer emergency or immediate medical treatment through telehealth.

9. Consent to Telehealth IMO

You acknowledge that:                                               

• You have read and understood this document and consent to participate in the telehealth IMO services provided by FarmUS Health Services.
• You understand the nature of telehealth services and their potential risks and benefits.
• You understand that the IMO is for evaluation purposes only and does not establish an ongoing doctor-patient relationship.
• You understand that telehealth has limitations and that an in-person evaluation may be necessary for certain aspects of care.
• You agree to provide accurate and complete information for the IMO.