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Agreement for Electronic Communication

_ Conditions of Using Electronic Communications

While the Service Provider will endeavour to review electronic communications in a timely manner, the Service Provider cannot provide a timeline as to when communications will be reviewed and responded to. Electronic communications will not and should not be used for medical emergencies or other time-sensitive matters. Electronic communication may not be an appropriate substitute for some services that the Service Provider offers. Electronic communications may be copied or recorded in full or in part and made part of your clinical chart. Other individuals authorized to access your clinical chart, such as staff and billing personnel, may have access to those communications. 

The Service Provider may forward electronic communications to staff and those involved in the delivery and administration of your care. The Service Provider will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.

Prior to the commencement of the provision of services by the Service Provider through electronic communications, the Service Provider and the patient will establish an emergency protocol to address the following:
  • Steps to be followed in the event of a technical issue that causes a disruption in the services that are being provided by the Service Provider; and
  • Steps to be followed in the event of a medical emergency that occurs during the provision of services.
The Service Provider Is not responsible for information loss due to technical failures associated with your software or internet service provider.  

The Patient will inform the Service Provider of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate electronically. 

The Patient will ensure the Service Provider is aware when they receive an electronic communication from the Service Provider, such as by a reply message or allowing “read receipts” to be sent.  

The Patient will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.  

If the Patient no longer consents to the use of electronic communications by the Service Provider, then the Patient will provide notice of the withdrawal of consent by email or other written communication. 

_ Risks of using electronic communication

While the Service Provider will use reasonable means to protect the security and confidentiality of information sent and received using electronic communications, because of the risks outlined below, the Service Provider cannot guarantee the security and confidentiality of electronic communications:  
  • Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
  • Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.
  • Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.
  • Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings. Electronic communications are subject to disruptions beyond the control of the Service Provider that may prevent the Service Provider from being able to provide services
  • Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Service Provider or the patient.
  • Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
  • Electronic communications may be disclosed in accordance with a duty to report or a court order.
  • Video conferencing using no cost, publicly available services may be more open to interception than other forms of videoconferencing. There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized.
  • Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.
  • Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

_Acknowledgement and Agreement

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above. I understand and accept the risks outlined above to this consent form, associated with the use of the electronic communications with the Service Provider and the Service Provider’s staff. I consent to the conditions and will follow the instructions outlined above, as well as any other conditions that the Service Provider may impose regarding electronic communications with patients. I acknowledge and agree to communicate with the Service Provider or the Service Provider’s staff using these electronic communications with a full understanding of the risks in doing so. I confirm that any questions that I had regarding the provision of healthcare services through electronic communications have been answered by the Service Provider.

Agreement for Teleoptometry Services

_ Conditions of Using Teleoptometry Services

Teleoptometry involves the use of electronic devices to enable 2­-way communication between patients and their doctors at different locations for the purpose of diagnosis, therapy, follow­up and/or education. Transmitted information may include any of the following:
  • Patient medical records
  • Live two-­way audio and video
  • Patient materials such as prescriptions and lab requisitions may be sent to the patients via email upon request
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. The alternative to a teleoptometry consult is an in-person visit with an optometrist.

_Benefits of using Teleoptometry Services

  • Improved access to optometric care by enabling a patient to remain in their home or workplace for simple issues such as medication refills, follow up appointments or urgent care needs.
  • More efficient medical evaluation and management.

_ Possible risks of using Teleoptometry services include, but may not be limited to

  • Specific medical conditions and/or technical problems may not allow for appropriate medical decision making by the optometrist, and an in-person consultation will be required.
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

_Acknowledgement and Agreement

By giving my informed consent, I understand the following:
  • I understand that the laws that protect privacy and the confidentiality of medical information also apply to teleoptometry, and that no information obtained in the use of teleoptometry which identifies me will be disclosed to researchers or other entities without my consent.
  • I understand that I have the right to withhold or withdraw my consent to the use of teleoptometry in the course of my care at any time, without affecting my right to future care or treatment.
  • All laws concerning patient access to medical records and copies of medical records apply to teleoptometry. I understand that I have the right to inspect all information obtained in the course of a teleoptometry interaction, and may receive copies of this information for a reasonable fee
  • I understand that I may choose to make an in person appointment at any time.
  • I understand that the doctor may recommend I schedule an in person appointment to address issues that cannot be adequately addressed through teleoptometry.
  • I understand that teleoptometry involves encrypted electronic communication of my personal medical information. Video, audio, and/or photo recordings may be taken during the procedure to aid in chart documentation
  • I understand that I may expect the anticipated benefits from the use of teleoptometry in my care, but that no results can be guaranteed or assured
  • There are fees associated with Teleoptometry consultation.  If available, a portion of the Teleoptometry fees will be billed to MSP­ on my behalf.  I understand that a balance fee is still applicable in addition to the portion covered by MSP. I agree to pay all applicable fees upon receipt of invoice.
  • I agree that any dispute arising from the teleoptometry consult will be resolved in the Province of British Columbia.

Agreement for Teleoptometry Services

_ Conditions of Using Teleoptometry Services

Teleoptometry involves the use of electronic devices to enable 2­-way communication between patients and their doctors at different locations for the purpose of diagnosis, therapy, follow­up and/or education. Transmitted information may include any of the following:
  • Patient medical records
  • Live two-­way audio and video
  • Patient materials such as prescriptions and lab requisitions may be sent to the patients via email upon request
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. The alternative to a teleoptometry consult is an in-person visit with an optometrist.

_Benefits of using Teleoptometry Services

  • Improved access to optometric care by enabling a patient to remain in their home or workplace for simple issues such as medication refills, follow up appointments or urgent care needs.
  • More efficient medical evaluation and management.

_ Possible risks of using Teleoptometry services include, but may not be limited to

  • Specific medical conditions and/or technical problems may not allow for appropriate medical decision making by the optometrist, and an in-person consultation will be required.
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

_Acknowledgement and Agreement

By giving my informed consent, I understand the following:
  • I understand that the laws that protect privacy and the confidentiality of medical information also apply to teleoptometry, and that no information obtained in the use of teleoptometry which identifies me will be disclosed to researchers or other entities without my consent.
  • I understand that I have the right to withhold or withdraw my consent to the use of teleoptometry in the course of my care at any time, without affecting my right to future care or treatment.
  • All laws concerning patient access to medical records and copies of medical records apply to teleoptometry. I understand that I have the right to inspect all information obtained in the course of a teleoptometry interaction, and may receive copies of this information for a reasonable fee
  • I understand that I may choose to make an in person appointment at any time.
  • I understand that the doctor may recommend I schedule an in person appointment to address issues that cannot be adequately addressed through teleoptometry.
  • I understand that teleoptometry involves encrypted electronic communication of my personal medical information. Video, audio, and/or photo recordings may be taken during the procedure to aid in chart documentation
  • I understand that I may expect the anticipated benefits from the use of teleoptometry in my care, but that no results can be guaranteed or assured
  • There are fees associated with Teleoptometry consultation.  If available, a portion of the Teleoptometry fees will be billed to MSP­ on my behalf.  I understand that a balance fee is still applicable in addition to the portion covered by MSP. I agree to pay all applicable fees upon receipt of invoice.
  • I agree that any dispute arising from the teleoptometry consult will be resolved in the Province of British Columbia.