Informed Consent

Informed Consent and Terms of Use

Please indicate your consent to and understanding of the terms and conditions of use of the Baylor Scott and White Health (BSWH) E-Visit system before starting your interview with a BSWH E-Visit health care provider.

I ACKNOWLEDGE THAT BAYLOR SCOTT AND WHITE E-VISITS ARE FOR THE ROUTINE, NON-URGENT “QUALIFYING MEDICAL CONDITIONS" LISTED BELOW, AND ARE NOT DESIGNED, INTENDED OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENT, OR LIFE-THREATENING MEDICAL CONDITIONS AND I WILL NOT ATTEMPT TO USE MY BSWH E-VISIT TO ADDRESS THESE CONDITIONS. IF I AM HAVING A MEDICAL EMERGENCY, I WILL DISCONTINUE MY BSWH E-VISIT AND CALL 911 OR GO TO THE NEAREST EMERGENCY DEPARTMENT. IF I AM EXPERIENCING SIGNIFICANT PAIN, BREATHING TROUBLE, DEHYDRATION, OR ANY OTHER DISTRESS THAT REQUIRES IMMEDIATE OR URGENT ATTENTION, I WILL DISCONTINUE MY BSWH E-VISIT AND CALL 911 OR GO TO THE CLOSEST EMERGENCY DEPARTMENT.

I acknowledge that the BSWH E-Visit service cannot and is not intended to replace the relationships I have with the health care professionals who treat me.

I understand and acknowledge that my E-Visit will establish a therapeutic clinician patient relationship and that my visit information will result in the creation of a medical record of BSWH E-Visit.

I acknowledge that I will be asked questions regarding the condition for which I am seeking medical care, and that I am obligated to answer questions truthfully. I agree that I will answer these questions completely and accurately and that, if I do not understand a question or do not know the answer to a question, I will stop my BSWH E-Visit and contact an available health care provider.

I agree that if I am instructed to discontinue my BSWH E-Visit and contact an available health care provider for any reason I will do so. I also agree to carefully follow any instructions I receive through my BSWH E-Visit and to ask for clarification of any instructions that I do not understand.

I attest that I am a resident of AND located in the State of Texas at the time I start this BSWH E-Visit interview.

I attest that I am at least 18 years of age, or, if this BSWH E-Visit interview is for a minor child, the child is at least 2 years of age and I am the child's parent or legal guardian and am legally authorized to seek care on his or her behalf.

I acknowledge that BSWH E-Visit is only available to eligible Scott and White Health Plan Members with a qualifying medical condition. For purposes of the BSWH E-Visit website, an “eligible Scott and White Health Plan Member" is an individual with health care benefits provided by the Scott and White Health Plan and who is eligible under applicable state laws to be treated using electronic or advanced telecommunications technology.

A “qualifying medical condition" is any of the following: Cold, Sinus Infection or Sore Throat; Female Bladder Infection; Hay Fever / Allergies; Influenza and Influenza Prevention; Pink Eye; and Vaginal Yeast Infection. All other ailments and medical conditions will require an appointment for a face-to-face evaluation by a medical provider.

I acknowledge that I have reviewed and agreed to the Fabric Labs, Inc. E-visit General Baylor Scott and White Health E-Visit Terms of Service. and I understand the Baylor Scott and White Health E-Visit Privacy Policy.

I acknowledge that I am solely responsible for maintaining the safety and security of my login ID and password.

Consent for treatment: I hereby consent to the use of the information I supply as part of the BSWH E-visit interview by non-physician advanced practice clinicians (e.g. nurse practitioners, physician's assistants and other advanced clinicians licensed to provide health care services in the State of Texas) to assess my condition and recommend an appropriate course of care. I understand that I will have a chance to discuss and / or refuse the care recommended by my BSWH E-Visit provider. I acknowledge that BSWH E-Visit providers cannot guarantee any specific results or ensure that all of concerns will be resolved during my BSWH E-Visit. I understand that my BSWH E-Visit provider is not able to provide care for all conditions and I may need to schedule an in-person appointment with a provider. I further understand that I should schedule an in-person appointment with a physician in the event my symptoms do not resolve within 72-hours following this E-Visit.

Electronic health record: BSWH E-Visit uses shared electronic health records. This allows care providers using this record to store, update and use my health information when needed at the time I am seeking care. The electronic health record allows better access to my health information, leading to better coordination and quality of care. This shared electronic health record is a secure system. For a list of the health care providers that use this shared electronic health record please contact us at the phone number listed below. I understand that if I require a copy of my BSWH E-Visit electronic health record, I may access my record at any time through my BSWH E-Visit account.

I acknowledge that any care provider who uses the shared electronic record may access and use my health records as needed to provide treatment (including coordinating my care), to improve the quality of care, and in accordance with the Scott and White Notice of Privacy Practices.

If I have questions about or concerns with any part of this consent, I will call the number below to discuss them. The authorizations on this form will remain valid until I revoke (withdraw) them in writing or until the law states they have expired. However, any actions already taken in reliance upon these authorizations will remain valid. (I cannot undo actions that were taken while my consent was valid.)

I may get help with this process at any time by contacting BSWH E-Visit at (855) 473-8763.

NOTE: Records may not be sent to your primary care provider. You may access your BSWH E-Visit medical record through BSWH E-Visit at any time.

By placing my initials where indicated in this form, I consent to and authorize the Baylor Scott and White Health E-Visit medical provider to assess my symptoms and health, and recommend treatment if necessary.