Telehealth is the use of certain telecommunications technology (such as live videoconferencing or “store-and-forward” image sharing) to assess, diagnose, treat, or otherwise serve a patient’s healthcare needs. Remedy Urgent Care PLLC and, for patients being treated in California, Remedy Medical of California PC (each, the “Provider”) provides some of its services, including without limitation evaluating patients with urgent care and acute care needs (the “Services”), via a secure video conferencing interface (the “Platform”). The Platform may also be used to schedule in-person home health visits with one of our practitioners.
Provider uses this Informed Consent form to help make sure that patients are aware of the ways in which telehealth differs from in-person healthcare services. Please read this form carefully and click the “I agree” button below if you are interested in receiving the telehealth Services from Provider through the Platform. (For purposes of this Informed Consent, “you” means the person receiving the Services. This Informed Consent should only be completed by the patient or someone legally authorized to make medical decisions on the patient’s behalf.)
You understand that the Platform is not intended to be used for emergency medical care. You understand that in a medical emergency you should dial 911 or visit an emergency room.
In using the Services on the Platform, you understand that you will be provided with the name, credentials, licensure, and qualifications of the individual licensed health care provider(s) (the “Practitioner(s)”) who will be providing your care.
You understand that by using the Platform for Services, you will not have an in-person physical exam that might identify a potentially serious medical condition. You also understand and agree that the health information you provide through the Platform may be the only source of health information used by the Practitioner(s) during the course of your evaluation and treatment through the Platform, and that such Practitioner(s) may not have access to any other health information held by your previous medical providers (e.g., allergies, drug reactions, etc.). You understand that you are not guaranteed treatment through the Platform and that Practitioner(s) will determine whether or not it is appropriate to treat you through the Platform using their independent professional judgment.
You certify that all of the information you provide through the Platform for the Services is true, accurate, and complete. You understand that if you knowingly provide false, misleading, or incomplete information to Provider or any Practitioner(s), it may have a negative effect on your treatment and your health. Provider reserves the right to terminate your access to the Platform if you knowingly provide incorrect information. You understand that you should ask questions about anything you do not understand. You understand that Practitioner(s) are available to answer any questions you may have when receiving Services through the Platform.
You understand that it is your responsibility to arrange and pay for any follow-up care that Provider or Practitioner(s) recommend you receive. You understand that you will be told how to get care in the case of an emergency.
You further understand that the electronic nature of the Service means that there is a greater risk to the privacy of your electronic health information relative to receiving in-person care. By agreeing to use the Platform, you are consenting to Provider sharing your personal information, including health information, with certain third parties as more fully described in our Notice of Privacy Practices, available here or, for patients receiving treatment in California, available here. In addition to the information you share with Provider through the Platform, the Platform may also collect your device identifier and your geolocation. You understand, agree, and expressly consent to Provider obtaining, using, storing, and disseminating to necessary third parties, information about you and your image, as necessary to provide Services through the Platform. You further understand that records of Services provided to you through the Platform may be lost through technical failures and could result in a breach of our confidentiality to you. You understand that if you are experiencing technical difficulties through the Platform, you may call us at 844-736-3395 or send us an email at email@example.com. You understand that technical issues in the Platform may result in a delay in receiving Services. In the event of an issue with connecting with the Platform, Provider or Practitioner(s) may contact you by phone to continue the Services. You hereby release and hold harmless Provider from any loss of data or information due to technical failures associated with the Platform.
You agree that it is your choice whether or not to use the Services on the Platform. You understand that at any time, you can change your mind about receiving Services via the Platform and may terminate your treatment with Provider or contact Provider or any Practitioner(s) to discuss alternate modes of treatment. If you would like to have the records relating to the Service received through the Platform sent to your primary care provider, you understand that you will need to request such transfer of records. You may obtain copies of your medical records for Services by emailing us at firstname.lastname@example.org faxing a request to 512-904-7575. Provider will respond to messages as they are received but does not guarantee an immediate response.
You understand that under applicable state laws, Provider or Practitioner(s) may be required to report suspicions of child abuse, neglect, statutory rape, domestic violence, and sexual assault. You hereby release and hold harmless Provider and Practitioner(s) for any good faith efforts to comply with state reporting laws.
You hereby consent to the use of telehealth to examine, consult, diagnose, or treat you and you understand that you may seek in-person care should you so choose.
You further acknowledge and agree that:
- If you are younger than eighteen (18) years of age, then your parent or legal guardian must consent to your use of the Platform and receipt of the Services.
- You understand that you have read and understood the information above, including the benefits, risks and limitations of using the Platform for Services, and you may seek in-person care or in-person follow up care with another provider of your choosing.
- Provider and Practitioner(s) may share your health records with other health care providers for purposes relating to the provision, coordination or management of your healthcare. This may include information relating to substance abuse, mental health, communicable diseases and other health conditions, subject to the terms in the Notice of Privacy Practices.
- Our Practitioner(s) may determine that our clinical services are not appropriate for some or all of your treatment needs and may elect not to provide Services to you through the Platform.
- This informed consent will become a part of your medical record.