INFORMED CONSENT FOR TELEHEALTH SERVICES
I understand that MoldCo will provide administrative services to facilitate connecting me with its network of physician practices (each a “Practice”) and an affiliated licensed health professional (“the “Professional”) via our online platform to provide healthcare for mold related health care conditions, including assessment, diagnosis, lab testing, treatment, follow-up and/or education telehealth including consultation, treatment, transfer of personal and health information, emails, telephone conversations and education using interactive audio, video and data communications (“Telehealth”). Telehealth involves the use of electronic communications. I hereby consent to engage in Telehealth services with my Professional. I understand that my Professional is an independent contractor and is not employed by MoldCo. My Professional may require me to execute an additional informed consent prior to engaging in Telehealth.
I understand that the expected benefits of Telehealth are improved access to health care for mold related illnesses enabling me to remain at a remote site while the Professional is at a distant site, more efficient evaluation and management and obtaining the expertise of a distant Professional who is licensed in the state where I reside.
I understand that I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my personal and health information for in-person health services. Any information disclosed by me during the course of my remote Telehealth, therefore, is generally confidential to the extent provided by law.
As with any medical care, there are potential risks associated with the use of Telehealth. These risks include, but may not be limited to: (a) in rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate professional decision making by the Professional; (b) delays in evaluation and treatment could occur due to deficiencies or failures of the equipment; and (c) the possibility of disruption, distortion or unauthorized access during transmission of personal information due to internet/electronic/technical failures beyond the control of MoldCo and my Professional.
By signing this form, I understand the following:
1. I understand that Telehealth is the use of electronic communication technologies by a health and/or therapeutic provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to the Professional to provide professional health care services to me via Telehealth.
2. I understand that I may be required to have certain system requirements to access electronic Telehealth services via the method chosen. I understand that I am solely responsible for any cost to obtain any additional/necessary system requirements, accessories, or software to use Telehealth services.
3. I understand that I have the right to withhold or withdraw my consent to the use of Telehealth by the Professional at any time, without affecting my right to future care or treatment.
4. I understand that a variety of alternative methods of health care may be available to me, and that I may choose one or more of these at any time.
5. I represent and warrant that all required information I provide to MoldCo and the Professional is truthful and accurate, and that I will maintain the accuracy of such information.
6. I understand that there are, by law, exceptions to confidentiality by a Professional including, but not limited to, reporting child, elder and dependent adult abuse; expressed threats of violence toward an ascertainable victim; my own mental or emotional state informing a clear danger to myself or others; where I make my health, mental or emotional state an issue in a legal proceeding; where otherwise required by law.
7. I understand that I am solely responsible for the privacy and confidentiality in my surrounding environment while engaged in telehealth and will exercise appropriate privacy measures.
8. I agree that if it becomes clear to the Professional, in his or her sole professional opinion, that the Telehealth modality is unable to provide all pertinent clinical information during the Telehealth encounter, the Professional will advise me prior to the conclusion of the live Telehealth encounter and will advise me regarding the need for me to obtain an additional in-person evaluation reasonably able to meet my needs and may make a referral to a Professional in my area.
9. I understand that I have a duty to inform my Professional of electronic interactions regarding my care that I may have with other healthcare providers.
10. I understand that Telehealth services may not be as complete as face-to-face services.
11. I understand that there are potential risks and benefits associated with any form of treatment, and despite my efforts and the efforts of my Professional, my condition may not improve, and in some cases may even get worse.
12. I have been given an opportunity to select a Professional prior to the consult, including a review of the consulting provider’s credentials.
13. I understand there is a risk of technical failures during the Telehealth encounter beyond the control of MoldCo or my Professional. I agree to hold harmless MoldCo, the Practice, and my Professional for delays in evaluation or for information lost due to such technical failures.
14. I understand that if I am experiencing a medical emergency or a crisis, that should dial 9-1-1 immediately and that MoldCo is not able to connect me directly to any local emergency services.
15. I understand that that a Professional will only take responsibility for my care after I have created an account on the Telehealth nd provided all requested information. Notwithstanding the foregoing, any Professional has the right to refuse to provide care to me if the Professional makes a professional judgment that I am not qualified to receive medical care through Telehealth. I EXPRESSLY ACKNOWLEDGE THAT A REQUEST FOR TREATMENT DOES NOT CREATE A PATIENT-PROVIDER RELATIONSHIP. NOTE: In order to create a physician/patient relationship THROUGH MY USE OF ANY OF THE TELEHEALTH SERVICES with a Professional, I must complete a medical history questionnaire and acknowledge/consent to any other forms as may be provided to utilize the Telehealth from time to time.
16. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes.
17. I understand that my Telehealth session will not be recorded without my consent. If I do consent to recording my Telehealth session, my Professional will document my consent in my clinical record.
18. I understand that I may verify the veracity of my Professional’s professional license by searching one of the following practitioner licensure data bases LINK (New York) LINK (Texas) LINK (Florida).
19. I understand that only when I have accurately and fully completed my medical history information and have had a Telehealth consultation, in compliance with state law governing the establishment of a legal provider/patient relationship, will I be eligible to get a prescription for any medications, as determined by the Professional in such Professional’s sole discretion and subject to the Professional’s professional and legal obligations. NOTE: No controlled substance medications are available through Professionals. If my Professional issues a prescription, I have the right to select the pharmacy of my choice. I agree that any prescriptions shall be solely for my personal use. I agree to fully and carefully read all provided product information and labels and to contact my Professional, a physician, other provider, or pharmacist if I have any questions regarding the prescription.
I have read and understand the information provided above regarding Telehealth and all of my questions have been answered to my satisfaction. By clicking the “I AGREE” button and typing my name and date of birth at the bottom of this page, I am authorizing the Practice and Professional to whom MoldCo facilitates a connection to assess my health via Telehealth and confirming my agreement and understanding of the statements above. I hereby give my informed consent and authorization for my Professional to use Telehealth in my healthcare.