Consent for Telehealth Services - Rugiet

Consent for Telehealth Services

Last updated January 17, 2020

 

Rx23, LLC uses Telehealth Services to connect users to third party health care providers (“HCPs”) to enable those providers to evaluate the individual’s medical information for the purpose of providing care. “Telehealth Services” may include remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) output data from medical devices and sound and video files.

 

Any “Telehealth Services” are in addition to, and not a replacement for, care you receive or received from a local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not. You may contact the HCPs with follow-up questions. However, if you are experiencing a medical emergency, you should dial 911 or go to your nearest emergency room or urgent care center immediately.

 

In order to proceed, you must confirm by clicking below that you have read, understood, and agree to this Consent for Telehealth Services.

 

  1. I consent to receive services using telehealth technologies. I understand that Telehealth Services do not replace overall medical care from my local primary care provider. I understand that, in the case of a medical emergency, I should dial 911 or go to the nearest emergency room or urgent care center immediately

 

  1. I understand that I am responsible for providing the HCPs with complete, truthful, and accurate information. I understand that an HCP will determine whether or not my specific needs are appropriate for a telehealth encounter, and that the HCP or I can discontinue any telehealth encounter. I understand that there is no guarantee that I will be given a prescription for medication.

 

  1. I understand that there is a risk of technical failures during Telehealth Services. I agree to hold Rx23 and the HCPs harmless for any delays in evaluation or for information lost due to such technical failures.

 

  1. I understand that federal and state laws require health care providers to protect the privacy and security of health information. I understand that Rx23 and the HCPs will take reasonable and appropriate steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including other states.

 

  1. I understand 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.

 

  1. I understand all the potential risks, consequences and benefits of telemedicine, as well as the alternatives to telemedicine. The risks/consequences include, but are not limited to, data breach with unauthorized access and personal/health information theft, lack of in person physical examination with the associated limitations, and technical interruptions/difficulties/failures. The alternative to telemedicine is an in person health care provider visit.

 

  1. I understand that I have the right to ask my health care provider about any information written on this consent form.

 

  1. I understand that I have the right to stop or refuse treatment at any time.

 

By clicking below, I acknowledge that I have read, understood, and agree to the terms of this Consent and that I have chosen to use Telehealth Services.