Consent for Use of Virtual Visit Webcam System
As the parent/legal guardian of an infant in the NICU at Phoenix Children’s Hospital (PCH) I hereby give my permission and authorize PCH to activate a Virtual Visit webcam system, which
will be located above my infant’s hospital bed, so that I can view my infant during his or her hospital stay.
I understand the following about the use of the Virtual Visit webcam system:
- I am responsible for the user name and password given to me. No other users will have access to my infant’s video unless I give them the user name and password. PCH is not responsible for any actions taken by people to whom I have provided a user name and password.
- PCH is not responsible for providing me with an internet access device.
- Recordings and/or copies of any Virtual Visit video are not allowed.
- Virtual Visit does not store any video or patient information.
- The purpose of the webcam is to view my infant. The webcam will be turned away or turned off during procedures. PCH and the medical team have the right to turn away or turn off the webcam at such times as PCH or the medical team determines.
- Information will be gathered about use of the Virtual Visit webcam system. Information collected will include how often each logon is used and for how long, and the information will be available to PCH.
- I may not be able to view my infant during times when technical problems occur with the Virtual Visit webcam system.
- If my infant is moved out of a hospital bed space that has a Virtual Visit webcam, I will not be able to view my infant through the Virtual Visit webcam system.
Expiration Date - This Consent expires when my infant is discharged from PCH.
Withdrawal of Consent - I understand that I may revoke this Consent at any time.
Release of Liability – I agree that PCH and its staff are hereby released from all legal responsibility and liability for the access and release of my information to the extent indicated and authorized herein.
Re-Disclosure – I understand that once the above-described information is disclosed, it may no longer be protected by privacy laws.
I am not required to accept this Consent. My refusal to accept this Consent will not deny treatment for my infant, and PCH will not condition treatment, payment, enrollment or eligibility for benefits on my accepting this Consent. However, no access to the Virtual Visit webcam will be permitted unless I accept this Consent.