Consent to Use Telehealth Services

BY ACCESSING AND USING THE TELEHEALTH SERVICES, INCLUDING BY PROVIDING INFORMATION AND RECEIVING HEALTHCARE SERVICES THROUGH THE TELEHEALTH SERVICES, YOU AGREE THAT YOUR PROVIDER’S (AS DEFINED BELOW) TERMS AND NOTICES OF PRIVACY PRACTICES APPLY TO THE TELEHEALTH SERVICES. YOU ALSO ACCEPT AND AGREE TO THOSE OF THE TECHNOLOGY PLATFORM PROVIDER, MODMED, FOUND AT TERMS OF USE AND PRIVACY POLICY. IF YOU DO NOT AGREE TO THIS CONSENT OR ANY SUCH TERMS OR PRIVACY POLICIES, THEN DO NOT ACCESS OR USE THE TELEHEALTH SERVICES.

In this consent, Modernizing Medicine, Inc., Modernizing Medicine Gastroenterology, Inc., and any of their affiliates offering telehealth services will be referred to as “ModMed” and terms like “we”, “our”, or “us”.

In this consent, the terms “you”, “yours”, and similar terms refer to the person using the telehealth services, which includes all content and products or services provided through the telehealth services. In the case of a use of the telehealth services by or on behalf of a minor, “you”, “yours”, and similar terms refer to both: (i) the parent or legal guardian who provides consent to the use of the telehealth services by such minor or uses the telehealth services on behalf of such minor and (ii) the applicable minor.

When using the telehealth services, you will be consulting with your healthcare providers (“Providers”). The telehealth services involve the delivery of healthcare services using electronic communications, information technology, or other means between a healthcare provider and a patient who are not in the same physical location. The telehealth services may be used for diagnosis, treatment, follow-up and patient education, and may include, but is not limited to, one or more of the following:

• Electronic transmission of medical records, photo images, personal health information, or other data between a patient and a healthcare provider;
• Interactions between a patient and healthcare provider via audio, video, or data communications; and
• Use of output data from medical devices and sound and video files.

Anticipated Benefits:

Your use of the telehealth services may have the following possible benefits:

• Making it easier and more efficient for you to access medical care and treatment for the conditions treated by Providers using the telehealth services;
• Allowing you to obtain medical care and treatment by Providers at times that are convenient for you; and
• Enabling you to interact with Providers without the necessity of an in-office appointment.

Possible Risks:

Although your use of the telehealth services may provide you potential benefits, there are also potential risks. These risks include, but may not be limited to the following:

• The information transmitted to your Providers may not be sufficient (e.g. poor image resolution) to allow your Provider to make an appropriate medical decision.
• Your Providers’ inability to conduct certain tests or assess vital signs in-person may in some cases prevent the Providers from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
• Your Providers may not able to provide medical treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services.
• Delays in medical evaluation/treatment or a failure to obtain needed treatment could occur due to unavailability of your Providers, deficiencies or failures of the technology or electronic equipment used, a transmission delay or failure, issues with the internet or other communications means, or for other reasons.
• The electronic systems, public networks, or security protocols or safeguards used in the telehealth services could fail, causing a breach of privacy of your medical or other information.
• Your Providers’ diagnosis and treatment options, especially pertaining to certain prescriptions, may be limited.
• A lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By using the telehealth services you understand, agree to, and provide your consent to, on behalf of yourself and, if applicable, any minor child using the telehealth services or on whose behalf the telehealth services is being used, the following:

• ModMed is not a healthcare provider and your Providers will be solely responsible for any medical care and treatment provided or failed to be provided via the telehealth services.
• The delivery of healthcare services via telehealth services is an evolving field and the use of telehealth services in your medical care and treatment from Providers may include uses of technology not described in or different from those described in this consent.
• No potential benefits from the use of the telehealth services, care provided via the telehealth services, or specific results can be guaranteed. Your condition may not be cured or improved and in some cases may get worse.
• There are limitations in the provision of medical care and treatment via the telehealth services and you may not be able to receive diagnosis or treatment through the telehealth services for every condition for which you seek diagnosis or treatment.
• There are potential risks to the use of the telehealth services, including the risks described in this consent.
• Your Providers have discussed the use of the telehealth services with you, including the benefits and risks of such use and the alternatives to the use of the telehealth services, and you have provided consent to your Providers for the use of the telehealth services.
• You have the right to withdraw your consent to the use of the telehealth services in the course of your care at any time, which you may exercise by providing written notice to [email protected]. The withdrawal of such consent will prevent you from using the telehealth services, but you may continue to seek medical care and treatment from your Providers outside of the telehealth services and your withdrawal will not impair your rights to receive such medical care and treatment outside of the telehealth services. Your withdrawal of consent will be effective upon receipt of the written notice described above, except that such withdrawal will not have any effect on any action taken by ModMed or your Providers in reliance on this consent before it received your written notice of withdrawal.
• Nothing in this consent modifies any rights you may have to review or receive a copy of your medical records from your Providers, including any information included in such medical records that has been transmitted to your Providers through the telehealth services.
• You have read the Notice of Privacy Practices provided to you outside of the telehealth services by your Providers and you understand that your medical information is subject to all applicable laws regarding the confidentiality of such medical information. You have the right to access and amend your medical information as and to the extent permitted under applicable law.
• You understand that the use of the telehealth services involves electronic communication of your personal medical information to Providers who may be located in other areas, including outside of the state in which you reside.
• You understand that it is your duty to provide ModMed and your Providers truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from other healthcare providers outside of the telehealth services.
• You understand that each of your Providers may determine that your condition is not suitable for diagnosis or treatment using the telehealth services and that you may need to seek medical care and treatment from your Providers, a specialist, or other healthcare provider outside of the telehealth services.
• You acknowledge that some photographic or other images you submit to the telehealth services that will be shared with Providers may include portions of all of your breast or genitalia, and your Providers will receive such images solely for the purposes of such Providers providing you medical care and treatment via the telehealth services.
• You understand that you are fully responsible for payment for all fees billed to you through the telehealth services.
• You represent that: (i) you have read this consent carefully, (ii) you understand the risks and benefits of the telehealth services and its use in the medical care and treatment provided to you by Providers using the telehealth services, and (iii) you have the legal capacity and authority to provide this consent for yourself and the minor for which you are consenting under applicable federal and state laws, including laws relating to the age of majority or parental/guardian consent.
• You give your informed consent to the use of the telehealth services by Providers using the telehealth services under the terms described in the Terms of Use and this consent.
• Some telehealth services use short message service (SMS) to send you text messages. Standard message and data rates may apply. Please contact your Providers to stop SMS messages. Technical restrictions apply.