‍CONSENT FOR TREATMENT: I consent to and authorize Vynca to provide medical and nursing care, treatment, social support, and other healthcare and health-related services tailored to my needs. This care may also include assistance with advance care planning, discussions regarding my treatment preferences, goals of care, and end-of-life decision-making. I understand that my treatment plan may be adjusted as my condition evolves and that I have the right to ask questions, request changes to my care, or withdraw my consent at any time.

ASSIGNMENT OF BENEFITS: I authorize payment of my insurance benefit directly to Vynca for services provided. I further authorize Vynca to release my medical records and other necessary information to my insurance in order to submit claims on my behalf. I understand that I am responsible for any charges that are not covered or paid by my insurance and agree to pay for those services directly as permissible under my insurance policy. 

FINANCIAL RESPONSIBILITY: Your insurance may provide comprehensive coverage for your care, in which case the costs of your services will be covered by your insurance, and there will be no additional direct costs to you. However, if your insurance has a deductible, copay, or coinsurance, you will be responsible for these costs as specified by your insurance provider.

If you lose or change your coverage, you may need to disenroll from Vynca’s services. Additionally, if your insurance does not provide coverage for your care, you have the option to self-pay for these services.

CONSENT FOR TELEHEALTH SERVICES: I understand that telehealth services involve the use of electronic communications to provide healthcare services. I acknowledge that there are risks associated with telehealth, such as internet connectivity issues, video and audio disruptions, and system failures, which may impact the quality of care. While Vynca will take steps to protect my privacy, I am aware that there is also risk of unauthorized access to my health information.

I understand that telehealth may not be appropriate for all conditions and that in certain cases, a physical exam may be required. In emergencies or urgent care situations, I will seek in-person care or immediate medical attention as needed. 

I consent to receive telehealth services from Vynca, understand the risks associated with telehealth, and acknowledge my right to ask questions or discontinue telehealth services at any time.

ELECTRONIC COMMUNICATION: In addition to telehealth services, Vynca may use electronic communication to discuss my healthcare needs, including appointment reminders, test results, and other health-related matters. I understand that electronic communication may include methods such as email, text messages, or through the Vynca portal. I also understand that while Vynca will take reasonable precautions to protect my health information, these methods of communication may not be fully secure, and there is a risk of unauthorized access to my personal health information. 

I further consent to receiving communications from Vynca related to new services, promotions, and other offerings, including but not limited to calls, emails, text messages, or notifications through the Vynca portal. These communications may include information about new healthcare services, programs, or other opportunities that Vynca believes may be of interest to me. I understand that I can opt out of these communications at any time by notifying Vynca in writing or following the instructions provided in the communication.

I consent to receive electronic communications from Vynca and can revoke or modify this consent at any time.

FEEDBACK AND SURVEYS: I authorize Vynca to contact me regarding my healthcare experience, treatment, and satisfaction. This may include sending me surveys through mail, email, text, or through the Vynca portal. I understand that participation in these surveys is voluntary and will not impact my care if I choose not to participate. I understand that the information I provide will be used solely to improve care and services and will not be shared with third parties outside of Vynca unless required by law. I acknowledge that I may revoke my consent to receive surveys at any time by contacting Vynca in writing.

PATIENT ACKNOWLEDGMENT  

I acknowledge that I have read and understood the above sections of this consent form, including the risks and my rights. I consent to receive services from Vynca as outlined in this document and understand that I can withdraw my consent at any time.