Telehealth Consent

 

ALLERMI PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM.  PLEASE DO NOT ATTEMPT TO CONTACT ALLERMI, INC., PRACTICE OR YOUR PROVIDER.  AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.

Introduction

Telehealth is a mode of delivering health care services via communication technologies (e.g., Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care.

You are reviewing and acknowledging this Telehealth Consent Form because you, or a minor patient between the ages of 13 and 18 for whom you are the parent or legal guardian, are seeking healthcare services (“Services”) offered via Allermi-contracted medical practices, including Allermi Medical Associates, PC, Allermi California PC and Allermi Primary Medical Corporation (collectively, “Practice”), utilizing telehealth technologies facilitated through the Allermi website, iOS mobile app, web mobile app, or any partner platform, mobile app, or web mobile technologies (collectively, the “Allermi Platform”). This Telehealth Consent form supplements but does not modify or supersede any Terms of Use, Privacy Policy, or Notice of Privacy Practices of Practice or other healthcare providers offering services via the Allermi Platform.

Telehealth has certain expected benefits as well as service limitations and possible risks. Telehealth may improve access to care by enabling you to remain in your home while your provider consults and obtains test results at distant/other sites. It may:  (a) enable more efficient care evaluation and management, (b) enable you to more easily obtain expertise of a specialist as appropriate, and (c) provide a simpler avenue for you to contact your healthcare provider for follow-up questions by directly sending a message via a portal. The primary difference between telehealth and direct in-person service delivery is the inability for a healthcare provider to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your provider will make that determination. Telehealth also presents certain potential risks, including delays in evaluation and treatment due to deficiencies or failures of the equipment and technologies, or provider availability. In rare events, your provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor. In very rare events, security protocols could fail, causing a breach of privacy of personal medical information, or a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By [clicking “I consent to telehealth” and signing below], you indicate that:  (a) you are a patient, or parent or legal guardian of a minor patient; (b) you have reviewed this Telehealth Consent Form or had it explained to you; (c) you understand the risks and limitations of using telehealth technologies; (d) you have been given the opportunity to ask questions and that such questions have been answered to your satisfaction; and (e) you consent to receiving the Services from licensed health care providers employed by or contracted with Allermi (“Allermi Providers”) who are located at sites remote from you.

Treatment-Specific Consent

By clicking “I agree" you understand and agree to the following:

1. I am seeking Services for myself or on behalf of a minor patient between the ages of 13 and 18 for whom I am the parent or legal guardian. If I am consenting on behalf of a minor child, I certify that I am the child’s parent or legal guardian and that I have the legal right to consent to the minor child’s health care.  I acknowledge that Allermi does not provide Services to children younger than 13.
2. I understand that I could seek an in-office physician visit rather than obtain care via the Allermi Platform, and am choosing to participate in a Telehealth consultation. I understand that the Services do not replace the relationship between me and my primary care doctor, or between my child and my child’s pediatrician. I also understand it is up to my Allermi Provider to determine whether a telehealth encounter is appropriate for my or my child’s specific clinical needs.
3. I understand a licensed Allermi Provider will be assigned to me or my child prior to the consult, however, I can request a different licensed Allermi Provider at any time and may review the credentials of my assigned Allermi Provider.
4. I understand that the Services are conducted through store and forward or videoconferencing technology and my Allermi Provider will not be physically present in  the room.
5. I understand there are potential risks to the use of telehealth technology, including but not limited to, interruptions, delays, unauthorized access, and or other technical difficulties. I understand that either my Allermi Provider or I can discontinue the telehealth appointment if the technical connections are not adequate for the visit. I AGREE TO HOLD HARMLESS ALLERMI INC. AND PRACTICE, AND EACH OF THEIR RESPECTIVE EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR DELAYS IN EVALUATION OR FOR INFORMATION LOST DUE TO SUCH TECHNICAL FAILURES.
6. To protect the confidentiality of my health information, I agree to undertake my telehealth visit in a private location, and I understand that my Allermi Provider will similarly be in a private location. If any other individuals are present (i.e., for technological or translation assistance), I will be informed of the individual’s presence and such individual’s role, and will have the right to request the following: (1) omit specific details of my or my child’s medical history/examination that are personally sensitive; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
7. I understand that my unauthorized recording (audio, video, still photography, etc.) of any Telehealth visit with an Allermi Provider is strictly prohibited.
8. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand all medical reports resulting from the telehealth visit are part of my or my child’s medical record.
9. I understand that Practice will take steps to make sure that my or my child’s health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of personal medical information to other health practitioners who may be located in other areas, including out of state.
10. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting any right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason.
11. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
12. I understand that I or my child will not be prescribed any narcotics for any reason, nor is there any guarantee that a prescription will be given at all. I understand that the decision of whether a prescription is appropriate will be made in the professional judgment of my Allermi Provider.
13. I understand I can choose to fill my prescription at a pharmacy of my choice.
14. I understand that my Allermi Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Allermi Provider, the provision of the Services is not medically or ethically appropriate.
15. I understand that if I participate in a consultation, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.
16. I understand if I communicate with my Allermi Provider in a language other than English, my Allermi Provider will utilize a third-party translation service to assist in communicating with me and such service will receive my personal information, including health information.  This translation is free of charge.  I understand I am solely responsible for providing complete and accurate information to my Allermi Provider and third-party translation service.  I AGREE TO HOLD HARMLESS ALLERMI INC., PRACTICE AND THEIR RESPECTIVE EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS, MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS, PREDECESSORS, AND SUCCESSORS FOR ANY CLAIMS, LOSSES, OR DEMANDS CAUSED IN WHOLE OR IN PART BY THE USE OF A THIRD-PARTY TRANSLATION SERVICE.
17. I understand that I am responsible for payment of any amounts due and owing resulting from my telehealth visit.
18. I understand that Allermi Providers do not address medical emergencies via the Allermi Platform. I understand that the responsibility of my Allermi Provider may be to direct me or my child to emergency medical services, such as dialing 9-1-1 or going to an emergency room. I understand that my Allermi Provider will not be able to connect me directly to any local emergency services.
19. I agree that Allermi Inc. is a third party beneficiary of this Telehealth Consent form and has the right to enforce it against me.

CONSENT TO TEXT OR EMAIL USAGE FOR APPOINTMENT AND OTHER HEALTHCARE REMINDERS AND GENERAL INFORMATION

By checking this box and clicking “I accept” below, I further authorize Allermi Medical Group, P.C., Allermi California P.C., Allermi Primary Medical Corporation, and their affiliated entities (collectively, “Allermi”) to contact me by phone or SMS/ text message at the telephone number I have provided, or to send emails at the email address I have provided, with appointment reminders and general health information. I understand that this request is to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I also acknowledge this means of communication is not considered secure for the transmission of private information. 

Additional State-Specific Disclosures.

The following consents apply to users accessing the Allermi Platform for the purposes of participating in a telehealth consultation with an Allermi Provider as required by the states listed below:

Alaska: I understand my primary care provider may obtain a copy of my records of my telehealth encounter. (Alaska Stat. § 08.64.364).

Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the telemedicine consultation are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law. (Ariz. Rev. Stat. Ann. § 36-3602).

California: The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

NOTICE TO PATIENTS

California: Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov,email: licensecheck@mbc.ca.gov, or call (800) 633-2322. https://www.mbc.ca.gov/licensing/Notice-to-Consumers.aspx. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, or the physician assistant board’s website.

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. (Conn. Gen. Stat. Ann. § 19a-906).

District of Columbia: I have been informed of alternate forms of communication between me and a provider or other treating physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

Georgia: I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)). I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Idaho:  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Indiana:  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Louisiana: I understand the role of other health care providers that may be present during the consultation other than my assigned Provider. (46 La. Admin. Code Pt XLV, § 7511).

Maine:  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

Nebraska: I retain the option to refuse the telehealth consultation at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. I shall have access to all medical information resulting from the telehealth consultation as provided by law for access to my medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without my written consent. (Neb. Rev. Stat. Ann. § 71-8505;).

New Hampshire: I understand that the Allermi Provider may forward my medical records to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. I understand that by creating a treatment plan for me, the provider has reviewed my medical history and photos and in the provider’s assessment, the provider is able to meet in-person standard of care requirements when using asynchronous store-and-forward technology.(N.J.§ 45:1-62)

New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit here.

Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website; Or, the Oklahoma Board of Osteopathic Examiners’ website.

Rhode Island: If I use e-mail or text-based technology to communicate with my Allermi Provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. I acknowledge that my failure to comply with this agreement may result in the Allermi Provider terminating the e-mail relationship. (Rhode Island Medical Board Guidelines). I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.

South Carolina: I understand my medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).

Texas: I understand that my medical records may be sent to my primary care provider. (Tex. Occ. Code Ann. § 111.005). I have been informed of the following notice: NOTICE CONCERNING COMPLAINTS - Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants 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, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us. AVISO SOBRE LAS QUEJAS - Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Utah: I understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. I understand that the telehealth services provided through the Allermi Platform meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(9)(b)(ii), if applicable. I was warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the Provider harmless for such loss. I have been provided with the location of Allermi’s website and contact information. I was able to select my Provider of choice, to the extent possible. I was able to select my pharmacy of choice. I am able to a (i) access, supplement, and amend my patient-provided personal health information; (ii) contact my Allermi Provider for subsequent care; (iii) obtain upon request an electronic or hard copy of my medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another Provider of my medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-602).

Virginia: I acknowledge that I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless Allermi for information lost due to technical failures; and I provide my express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving tele-dermatology or tele-ophthalmology services via the Allermi Platform does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361(e)).  I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website; or, the Vermont Board of Osteopathic Examiners’ website.

Wyoming: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website.