855-211-5532 [email protected]


Introduction. Telemedicine involves the real-time evaluation, diagnosis, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. Telemedicine allows the provider to see and communicate with the patient in real-time.

Consent for Treatment. I voluntarily request Victory Select physician(s) and such associates, technical assistants and other health care providers as they may deem necessary, to participate in my medical care through the use of telemedicine.?

I understand that Victory Select Telemedicine Providers (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on medical and historical information provided by me. I acknowledge that Victory Select Telemedicine Providers? advice, recommendations, and/or decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my ultimate responsibility to provide information about my medical history, current conditions and any other relevant aspects of my healthcare that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science.? I furthermore acknowledge that no warranties or guarantees are made to me in regard to resolution or cure.

If Victory Select Telemedicine Providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted or ended due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If I experience any type of urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies dial 911, or go to the nearest hospital emergency department.

Release of Information. To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of any and all parts of my medical record (including oral information) to Victory Select Telemedicine Providers. I understand and agree that the information I am authorizing to be released may include: 1) AIDS/HIV test results, diagnosis, treatment, and related information: 2) drug screen results and information about drug and alcohol use and treatment; 3) mental health information; and 4) genetic information.

I understand that the disclosure of my medical information to Victory Select Telemedicine Providers, including the audio and/or video, will be by electronic transmission. Although precautions are always taken to adhere to HIPAA guidelines and to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering.

I certify that I have read this consent or have had it read to me, and that I fully understand its contents.


Patient concerns are important to us.? Therefore, it is imperative that we are notified in the event of an issue arising so that we can address them to ensure resolution.?

A patient has the right to communicate via verbal or written complaint.? Any concern regarding any aspect of said visit (care received, level of service provided, conditions, billing, etc.) and expect a timely response. If you have comments, questions, or concerns, we recommend that you or your HIPAA delegated representative:

  • Discuss them with your immediate caregiver, or
  • Speak to the manager of the clinic or service in which you are receiving care or
  • Email the patient services department at [email protected]


Complaints about physicians/physician assistants/nurse practitioners as well as other licensees and registrants of Texas Medical Board may be reported for investigation at the following address:

Texas Medical Board
Attention: Investigations
333 Guadalupe, Tower 3, Suite 610
P.O. Box 2018, MC-263
Austin, TX 78768-2018

Assistance filing a complaint is available by calling the following telephone number:?1-800-201-9353.

For more information please visit the Texas Medical Board website at www.tmb.state.tx.us