Consent Forms Notice

Effective Date: July 3, 2025

Last Updated: July 3, 2025

Overview of Consent Requirements

Virtual Concierge MD requires various consent forms to ensure you understand and agree to the terms of your medical care. This notice explains the consent forms you may be asked to complete.

Types of Consent Forms

1. General Medical Consent

Required for: All patients

Purpose: Authorizes routine medical care and treatment

Includes:

1. Permission to examine and treat
2. Understanding of medical services
3. Acknowledgment of policies
4. Financial responsibility

2. Telehealth Consent

Required for: All virtual visits

Purpose: Specific consent for telemedicine services

Includes:

1. Technology requirements
2. Privacy limitations
3. Geographic restrictions
4. Emergency protocols

3. HIPAA Authorization

Required for: All patients

Purpose: Privacy and information sharing

Includes:

1. How we use your information
2. Your privacy rights
3. Disclosure authorizations
4. Communication preferences

4. Financial Consent

Required for: All patients

Purpose: Payment and billing authorization

Includes:

1. Payment responsibility
2. Insurance processing
3. Collection policies
4. Refund terms

5. Prescription Consent

Required for: Patients receiving prescriptions

Purpose: Medication-specific agreements

Includes:

1. Controlled substance agreements
2. Medication risks and benefits
3. Compliance requirements
4. Monitoring consent

6. Procedure-Specific Consents

Required for: Specific treatments

May include:

1. Hormone therapy consent
2. Weight loss program agreement
3. Aesthetic treatment consent
4. Clinical trial participation

Special Consent Situations

Minor Patients

1. Parental/guardian consent required
2. Adolescent consent for certain services
3. State-specific requirements
4. Emancipated minor documentation

Sensitive Services

Enhanced consent for:

1. Mental health treatment
2. Substance use treatment
3. Sexual health services
4. Genetic testing

Research Participation

Additional consent for:

1. Clinical studies
2. Data collection
3. Publication permissions
4. Future contact

Consent Process

Before Your First Visit

1. Create patient account
2. Complete required forms online
3. Upload identification
4. Review and sign electronically

During Consultation

1. Provider reviews consents
2. Questions answered
3. Additional consents as needed
4. Verbal confirmation recorded

Ongoing Care

1. Annual consent updates
2. New consents for new services
3. Right to revoke certain consents
4. Documentation maintained

Electronic Consent

E-Signature Requirements

1. Legal name required
2. Date and time stamped
3. IP address recorded
4. Copy provided to you

Technical Requirements

1. PDF viewer needed
2. Secure portal access
3. Email for copies
4. Download capability

Your Rights

Right to Review

1. Read all forms carefully
2. Ask questions
3. Request clarification
4. Take time to decide

Right to Refuse

1. Decline specific services
2. Refuse certain disclosures
3. Opt-out of communications
4. Seek second opinions

Right to Revoke

Some consents can be revoked:

1. Marketing communications
2. Research participation
3. Certain authorizations
4. Future services

Required Acknowledgments

By signing consents, you acknowledge:

1. Understanding of services
2. Agreement to terms
3. Financial responsibility
4. Privacy practices
5. Communication preferences

State-Specific Requirements

California

1. Specific language requirements
2. Additional privacy rights
3. Minor consent provisions
4. Surprise billing protections

Illinois

1. Written consent preferences
2. Enhanced privacy protections
3. Specific telehealth requirements

Indiana

1. Telehealth-specific consents
2. Controlled substance requirements
3. Prior relationship documentation

Montana

1. Rural health provisions
2. Licensure acknowledgments
3. Service area limitations

New York

1. Provider location disclosure
2. Enhanced consent requirements
3. Additional privacy protections

Nevada

1. Specific documentation requirements
2. Expedited service acknowledgments
3. Privacy law compliance

Consent Form Storage

How We Maintain Records

1. Secure electronic storage
2. HIPAA-compliant systems
3. Backup procedures
4. Retention per law

Your Access

1. Patient portal access
2. Download capabilities
3. Request printed copies
4. Update procedures

Special Populations

Non-English Speakers

1. Translation services available
2. Interpreter documentation
3. Preferred language noted
4. Culturally appropriate forms

Disability Accommodations

1. Alternative formats available
2. Assistance provided
3. Extra time allowed
4. Accessibility ensured

Updates and Changes

When Updates Needed

1. Annual reviews
2. Service changes
3. Regulatory updates
4. Your request

Notification Process

1. Email notifications
2. Portal messages
3. Required re-signing
4. Grace periods

Common Questions

Do I need to sign everything?

Core consents are mandatory; some optional services have separate consents.

Can family members sign?

Only with proper authorization (POA, guardianship, etc.)

How long are consents valid?

Generally one year, some longer, some per-service.

Can I change my mind?

Yes, for many consents, with proper notice.

Assistance Available

We Can Help With:

1. Understanding forms
2. Technical issues
3. Language barriers
4. Accessibility needs
5. Questions or concerns

Contact Information

For Consent Form Questions:

Virtual Concierge MD

Patient Services Department

9663 Santa Monica Blvd, Suite 957

Beverly Hills, CA 90210

Phone: (310) 275-8377

Email: consents@virtualconciergemd.com

Office Hours:

Monday - Friday: 9:00 AM - 5:00 PM PST

Important Reminders

1. Read all forms carefully
2. Ask questions before signing
3. Keep copies for your records
4. Update information as needed
5. Understand your commitments

Informed consent is a cornerstone of ethical medical practice. We are committed to ensuring you understand all aspects of your care.