Informed Consent

By clicking “I Accept” or by accessing or using Allina Health Online Questionnaire Service, you agree to the following statements.

If I am experiencing a health-related emergency, I will call 911.

Allina Health Online Questionnaire is not meant to address serious, emergency, or life-threatening medical conditions and should not be used in those circumstances. Instead, if I feel that my symptoms are significant, I will seek medical care right away.

I am located in either Minnesota or Wisconsin at the time I start this Allina Health Online Questionnaire visit.

I will answer questions truthfully and that if I do not understand a question I will stop using Allina Health Online Questionnaire.

My Allina Health Online Questionnaire visit will establish a therapeutic clinician patient relationship and my visit information will result in the creation of a medical record of Allina Health. My medical record will be retained according to organizational policies and procedures and regulatory guidelines. Allina Health may use this information for standard treatment, payment, and operational purposes and in accordance with its Notice of Privacy Practices.

I am choosing to engage in a virtual medicine consultation. Allina Health Online Questionnaire provides an on-line healthcare service that allows me to submit a clinical history and symptoms for common minor health care conditions supported within the service menu. Based on the information that I provide, a licensed health care provider will provide a diagnosis and treatment plan. If appropriate, I may be referred to an alternative setting to receive care.

Records are not automatically sent to my referring physician. I may access my medical record through Allina Health Online Questionnaire.

If you are requesting this visit be billed to insurance, you agree to the following:

Assignment of Benefits: I request payment of authorized benefits directly to the Allina Health for services furnished to me during this on-line healthcare visit.

Guarantee and Agreement to Pay: I agree to pay the charges for the care and treatment rendered to me not covered by my insurance plan. I understand that 6% interest per year may be added if the account balance goes to a collection agency.