Privacy & Data Governance
Psychiatry Medical Services Inc.
Consent to Use Virtual Care Tools
This form is intended to facilitate an informed discussion regarding the risks and conditions of virtual care.
PHYSICIAN INFORMATION
Physician:Dr. Tyler R. Black
Medical Corporation: Dr. Tyler R. Black, Psychiatry Medical Services Inc.
The Physician has offered to provide the following means of virtual care (“the Services”):
Videoconferencing (Google Meet)
Website/Portal (Secure Document Uploader)
PATIENT ACKNOWLEDGMENT AND AGREEMENT
I acknowledge that I have read and fully understand the risks, limitations, and instructions for use of the selected Services described in the Appendix to this form. I understand that despite recommendations for encryption, it is possible that interactions may not be encrypted, and I accept this risk. Either I or the Physician may withdraw this option at any time with written notice.
APPENDIX: RISKS AND CONDITIONS
Risks of Virtual Care Tools
- Security Limits: Information sent via virtual tools can be intercepted, circulated, or changed without permission.
- Third-Party Access: Employers and online services may have a legal right to inspect communications that pass through their systems.
- Technical Risks: Tools can introduce malware or damage computer networks. Deleting a message does not guarantee that backup copies do not exist.
- Human Error: Emails or texts can be misdirected to unintended recipients.
Conditions of Use
- No Emergencies: Virtual care tools must not be used for medical emergencies or time-sensitive matters. If assistance is urgent, please go to the nearest Emergency Department or call 911.
- Response Times: The Physician cannot guarantee immediate review or response to electronic messages.
- Medical Record: Communications concerning diagnosis or treatment may be made part of your permanent medical record.
- Data Residency: Clinical records are stored in Montreal (northeast1), Canada. Encrypted transient data may be processed on secure global servers.
Instructions
- Conduct encounters in a private setting using a secure device.
- Do not record any encounter without the Physician’s prior consent.
- Inform the Physician immediately of any changes to your contact information.
- Take precautions to ensure your privacy and safeguarding passwords.
I have reviewed and understand all risks, conditions, and instructions described in this Appendix.
Contact: privacyofficer@tylerblack.com
Responsible for compliance with PIPA (BC) and PIPEDA (Canada).