TERMS OF SERVICE

BY receiving care, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT
CONSENT FOR TELEHEALTH or IN PERSON CONSULTATION
  1. I understand that my health care provider wishes me to engage in a telehealth consultation.
  2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
  3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
  4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
  5. I have read and understand the information provided above regarding telemedicine and I hereby give my informed consent for the use of telemedicine in my medical care. I hereby voluntarily give my consent to evaluation and treatment with Community Telehealth through means of all telehealth communications.
  6. I have read and understand the information provided regarding telemedicine and / or in person visits and accept the risks and benefits of telemedicine and / or in person visits and wish to receive such services
  7. I certify that I am a person with legal authority to act on behalf of myself or the patient, including the authority to consent to medical services, and accept financial and legal responsibility for services rendered
  8. I hereby agree to the policy and terms and give my informed consent for the use of telemedicine and / or in person visits in my medical care.
CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
  1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
  2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
  3. Telehealth via SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
  4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
  5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment and the visit will not be recorded by either party at any time including screenshots or audio throughout the visit.

Patient Consent and Agreement

Medical Consent

Telemedicine and or in person visits involve the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. I hereby voluntarily consent to all healthcare services ordered/provided by Community Telehealth’s providers at the Community Telehealth service locations. The health care service may include, without limitation, routine physical and mental assessment; diagnostic and monitoring tests and procedures; examinations and medical treatment; routine laboratory procedures and test; x-rays and other imaging studies; and procedures and treatments prescribed by the representative healthcare providers.
Providers may include primary care practitioners, specialists, and/or sub-specialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
  • Patient medical records
  • Medical images
  • Live two-way audio and video
  • Pictures
  • Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption under HIPPA guidelines
Expected Benefits:
  • Improved access to medical care by enabling a patient to remain in his/her provider’s office (or at a remote site) while the clinician obtains test results and consults from healthcare practitioners at distant/other sites.
  • More efficient medical evaluation and management.
  • Obtaining expertise of a distant specialist.
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
  • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the clinician and consultant(s);
  • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
  • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
  • In some cases, treatment failures may occur, you need to either book another appointment with Community Telehealth for further evaluation or seek a second opinion elsewhere.
By using this platform, I understand the following:
  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my written consent.
  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
  3. I understand that I give Community Telehealth consent to treat, and I have the right to inspect all information obtained in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
  4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
  5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state and will provide written consent for continuity of care as needed.
  6. I consent to receiving text messages , email reminders and or voicemails..
  7. I understand that it is my duty to inform my provider of other interactions regarding my care that I may have with other healthcare providers for continuity of care.
  8. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Consent to Treat a Minor

This form describes Community Telehealth’s treatment and payment policies for minor patients and includes:
  1. Your consent on behalf of the patient to receive medical treatment from Community Telehealth (and your other rights and responsibilities);
  2. You are the legal or authorized guardian to treat minor and will provide documentation if requested and your agreement on behalf of the patient to receive services using telehealth technology
  3. I understand that it is my duty to inform Community Telehealth of electronic interactions regarding my care that I may have with other healthcare providers.
  4. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
GENERAL PATIENT CONSENT FOR TREATMENT
Consent Provisions
  1. I certify that I have read and fully understand the foregoing consent and that the facts indicated above are true.
  2. I realize that although every effort will be made to keep all risks and side effects to a minimum, risks, side effects, and complications can be unpredictable both in nature and severity.
  3. I understand that Nurse Practitioners will be involved in treatment, and I consent thereto.
  4. I understand Community Telehealth will make every effort to keep communications confidential and secure.
  5. I hereby voluntarily give my consent to evaluation and treatment at Community Telehealth’s
Cancellation Policy
We understand that sometimes a patient is unable to make a scheduled appointment due to unforeseen circumstances. Community Telehealth’s cancellation policy makes booking, cancelling, and rescheduling easy.
Community Telehealth will honor a full refund for any of our visits when cancelled up to three (3) hours before the scheduled visit.
We are unable to offer refunds for the following:
  • No-shows or missed appointments for any reason
  • Refund requests due to not receiving a prescription or disagreement with the clinical guidance provided
  • We are sure you are aware that missing an appointment or being late prevents us from giving you the care needed and time you deserve. However, it is also detrimental to us as it prevents us from seeing our patients on time after your appointment.
Payment and Billing
When you use our Services, you are choosing to pay out-of-pocket for all products and services without using insurance or government healthcare programs. This means all services are self- pay only, and no insurance billing will occur.
By using our Services, you understand and agree to the following:
  1. Direct Payment Responsibility: You are voluntarily choosing to pay cash for all services and products rather than using federal or state healthcare programs (like Medicare or Medicaid). You are fully responsible for all costs.
  2. No Insurance Claims: Neither you, Community Telehealth, our partner labs, pharmacies, medical groups, nor healthcare providers will file claims with any government healthcare program to seek reimbursement for services or products you receive through our platform.
  3. I consent for Community Telehealth to charge my credit card for the cost of the per visit fee listed or the package fee listed. Visits to be used within 6 months from date of purchase for package rates, no refunds will be provided on unused visits