ED Alpha questionnaire survey
INFORMED CONSENT REGARDING USE OF TELEMEDICINE SERVICES
| Patient’s Legal Name | |
| Location | , |
| Date of birth | |
| Date of consent | 10/29/2019 |
| Telemedicine Services Provider | Foster Medical - (859)-300-6006 |
PURPOSE
Welcome to Alpha! Your health is important to us. Please carefully review the information below. This document is intended to inform you of the risks associated with telemedicine services. Your understanding of Telemedicine is important before any services can be provided to you.
WHAT IS TELEMEDCINE?
Telemedicine is a method for providing efficient medical care services using an interactive telecommunications system (e.g. the Internet or by phone) by a physician or practitioner who is licensed under State law to provide medical services to a patient in a location other than the location of the licensed medical practitioner (“Telemedicine Services”) . Telemedicine Services uses digital and electronic communications to enable a health care provider and patient to share medical information in order to evaluate, diagnose, consult, or treat the patient. The delivery of telemedicine healthcare allows the patient and medical care provider to establish a relationship from anywhere, independent of their location. In order to use the Telemedicine Services, you must have and maintain access to an interactive telecommunications system.
BENEFITS
Telemedicine Services provides improved access to medical services and care. This includes the expertise of specialists that may not be available for a face-to-face consultations. Telemedicine Services can also provide efficient care in evaluations, medical consultations, diagnoses, and treatment, leading to improved access to medical care.
POTENTIAL RISKS
Telemedicine Services offers an efficient way for medical care providers and patients to communicate and there are few risks associated with the use of Telemedicine Services. Potential risks include:
- Postponed medical evaluation and treatment due to telecommunication equipment failures or information transmission errors (e.g. poor image quality);
- Unauthorized access of protected health information (PHI) as a result of cyber security or other security breaches;
- Risks related to a patient withholding key medical information or records that may result in adverse or allergic reactions to prescribed drugs, and other complications.
DO I HAVE TO USE TELEMEDICINE?
Use of Telemedicine Services is voluntary and not required. You may always seek traditional, face-to-face medical care (e.g., face-to-face consultations or examinations between a medical care services provider and a patient).INDEMNIFICATION
YOUR USE OF THE TELEMEDICINE SERVICES IS VOLUNTARY. YOU AGREE TO INDEMNIFY & HOLD HARMLESS ALPHA MD, LLC, THE TELEMEDICINE SERVICES PROVIDER, AND THEIR RESPECTIVE MEMBERS, MANAGERS, REPRESENTATIVES, DIRECTORS, AGENTS, EMPLOYEES, PARENTS, SHAREHOLDERS, PREDECESSORS, OFFICERS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIMS, OR DEMANDS BROUGHT BY ANY PARTY WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE SERVICES WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO ALPHA MD, LLC OR THE TELEMEDICINE SERVICES PROVIDER’S NEGLIGENCE.
FOLLOW-UP CARE; EMERGENCY SITUATIONS
If you are experiencing a medical emergency call 911 or seek care at an emergency room facility or other provider equipped to deliver urgent care.
If there is an urgent situation in which you experience an adverse reaction, or technical difficulties prevent you from communicating with the Telemedicine Services Provider, or if you no longer wish to use Telemedicine Services, stop using the Telemedicine Services and please contact the Telemedicine Services Provider at the number listed above.
YOUR PRIVACY RIGHTS
We protect your patient information using industry standard network and software security protocols designed to safeguard the data you provide us. Your medical record, EMR, imaging, and personal financial data are all kept confidential using these protocols. Except as permitted by applicable law and as set forth in our Privacy Policy, your personal information, including your health information, will not be shared or disclosed to any third party without your consent.
By signing this form, I acknowledge that I have read and understand the risks and benefits of participating in Telemedicine Services and I have received answers to all of my questions to my satisfaction. I further acknowledge and agree that:
- I will need to provide my full and accurate medical history, including any pre-existing medical conditions, so that my provider can access and determine a treatment plan for me.
- That my provider will determine whether Telemedicine is appropriate for me based on my diagnosed or treated condition.
- I understand that my results cannot be guaranteed and that I may or may not benefit from any or all transactions regarding health services provided by Telemedicine.
- I will be informed by Telemedicine Services Provider of any persons present at the provider’s location during the Telemedicine service and I have the right to choose who may or may not be present.
- I understand that I have the right to object to any Telemedicine service without prejudice to any care or treatment that may take place in the future, and without risk of losing any health benefits to which I may be entitled.
- I understand that I will be informed of any charges associated with my Telemedicine services prior to incurring any charges and agree that I am responsible for paying the full amount of all costs associated with my Telemedicine services, including any prescriptions I receive.
- I agree that I will not make an attempt to submit a claim to Medicare, any other federal payor, or any state or private insurer regarding any fees for the Telemedicine Services.
- I understand that Telemedicine is also subject to the laws that protect my privacy and maintain the confidentiality of my medical information.
- I agree that Telemedicine Services Provider may provide my confidential health information to outside medical providers, potentially in other locations, as necessary.
- I have the right to view and obtain copies of all information exchanged during any Telemedicine session, concerning the policies of the physicians, assistants, nurse practitioners and facilities involved in my care.
- I understand I may be charged a fee required to receive copies of my records in accordance with applicable State regulations.
- All photos appearing on this site are models and not actual patients unless otherwise stated.
- The telephone number you provided during registration may be used to provide the Telemedicine Services to you and to contact you regarding your Telemedicine Services experience.
By clicking “I Agree” below, I understand and agree to the foregoing acknowledgements and disclosures including Telemedicine Services Provider’s Terms of Service and Notice of Privacy Practices. Alpha MD, LLC has a commercial and financial relationship with Telemedicine Services Provider I understand that I am free to obtain medical examination and advice from another healthcare provider that is not associated with Alpha MD, LLC at any time. I understand that Alpha MD, LLC will use its partner pharmacy to fulfill my prescription order(s), if any as a convenience to me. I understand that I am free to obtain my prescription from a pharmacy of my choice.
BY CLICKING “I Agree” I CONSENT AND PROVIDE MY ELECTRONIC SIGNATURE.
