On-line Agreement - Royal Flying Doctor Service

Online Agreement for new Flying Doctor Telehealth sites

Organisation Details

Name of organisation *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone number *

ABN *

Authorised Representative Details

Name *

First

Last

Email *

Phone *

Terms and conditions of use of the Flying Doctor Telehealth service:

The hosting of all telehealth appointments with patients will be held at the practice, including appropriate rooms for telehealth appointments, waiting area etc.

The practice will nominate one or more ‘Appointment Facilitator’ that will manage the booking and attendance of telehealth appointments for patients.

The practice will complete and return any forms relating to the appointment including but not limited to Medicare Db4 forms.

The practice will participate in evaluation activities including data collection and distributing patient feedback forms.

The practice will not share their allocated log in details with any other site.

The practice will implement locally appropriate strategies to manage DNAs (Did Not Attend).

The term of this agreement is for 24 months and following this the agreement will remain active until a new agreement is completed.

If either party want to cease this agreement prior to the 24 month period, confirmation of cessation must be received in writing.

All Royal Flying Doctor Service (RFDS) equipment must be returned to RFDS Victoria within 1 month of the termination of this agreement.

Agreement

On behalf of the organisation, I agree to the above terms and conditions.

I understand that my failure to comply with these conditions will result in my access to the Flying Doctor Telehealth platform being revoked from my organisation.

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