telehealth informed consent
Last updated: February 14, 2022
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE DIGITAL PLATFORM AND AS PART OF THE PROVIDER SERVICE OR OTHERWISE AFFIRMATIVELY ACCEPTING THIS CONSENT, YOU ACKNOWLEDGE THAT YOU HAVE READ, ACCEPTED, AND AGREED TO BE BOUND BY THIS CONSENT. IF YOU DO NOT AGREE TO THIS CONSENT, DO NOT CREATE AN ACCOUNT OR USE THE SERVICE. YOU HEREBY GRANT AGENCY AUTHORITY TO ANY PARTY WHO CLICKS ON THE “I AGREE” BUTTON OR OTHERWISE INDICATES ACCEPTANCE TO THIS CONSENT ON YOUR BEHALF.
IF YOU ARE EXPERIENCING A LIFE-THREATENING SITUATION SUCH AS CONTEMPLATING SUICIDE, CALL 911 OR THE NATIONAL SUICIDE PREVENTION LINE AT 1-800-273-TALK (8255)
The purpose of this consent form (“Consent”) is to provide you with information about telehealth and to obtain your informed consent to the use of telehealth in the delivery of healthcare and/or mental health services to you by third-party independent wellness and medical professionals and facilities offering their services (the “Provider”) using the proprietary mobile application and web-based platform, including content and any products or services provided through the platform, owned and operated by Awesome Health, doing business as Awesome Woman (collectively, the “Digital Platform”). In this Consent, the terms “you” and “yours” refer to the person using the Digital Platform.
Telehealth services offered by the Provider may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Provider Service”).
Awesome Woman does not provide the Provider Service; it performs administrative, payment, and other supportive activities for Provider.
USE OF TELEHEALTH
Telehealth involves the delivery of healthcare and/or mental health services using electronic communications, information technology or other means between a healthcare or mental health provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, therapy, follow-up and/or patient education, and may include, but is not limited to, one or more of the following:
- Appointment scheduling
- Diagnostic tests
- Medical images
- Electronic transmission of patient medical records
- Prescription refill reminders (if applicable)
- Live two-way audio and video between patient and Provider and/or data communications (such as messaging or email communications)
- Personal health information or other data between a patient and Provider
- Output data from medical devices and sound and video files
- Wearable devices used to gather biometric information such as ECG, pulse, blood pressure, etc.
Alternative methods of care may be available to you, such as in-person services, and you may choose an alternative at any time. Always discuss alternative options with the Provider.
The use of telehealth may have the following possible benefits:
- Improved access to care by enabling you to remain in your preferred location while the Provider consults with you.
- Convenient access to initial and follow-up care.
- More efficient care evaluation and management.
- Obtaining expertise of a distant specialist.
While the use of telehealth in the delivery of care can provide potential benefits for you, there are also potential risks associated with the use of telehealth and other technology. These risks include, but may not be limited to the following:
- The quality, accuracy or effectiveness of the services you receive from the Provider could be limited;
- Technology may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology, including the Provider Service, unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost;
- Failures of technology may also impact the Provider’s ability to correctly diagnose or treat your condition;
- The inability of the Provider to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you;
- The Provider may not able to provide treatment for your particular condition and you may be required to seek alternative healthcare or emergency care services;
- Delays in medical evaluation/treatment could occur due to unavailability of the Provider or deficiencies or failures of the technology or electronic equipment used;
- The electronic systems or other security protocols or safeguards used could fail, causing a breach of privacy of your personal medical information;
- Data stored and communicated electronically, for example, through email communications, may be more susceptible to unintended disclosure of protected health information to third parties;
- Given regulatory requirements in certain jurisdictions, the Provider diagnosis and/or treatment options, especially pertaining to certain prescriptions, may be limited;
- A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
If you are experiencing a life-threatening situation such as contemplating suicide, call 911 or the National Suicide Prevention Line at 1-800-273-TALK (8255).
If the situation is an emergency, call 911. The Provider does not address medical emergencies. If you require immediate or urgent care, you must seek care at an emergency room facility or other provider equipped to deliver urgent or emergent care. The Provider may not respond promptly to communications you submit through the Provider Service and/or the Digital Platform.
Additionally, the primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and the Provider will make that determination.
DATA PRIVACY AND PROTECTION
The electronic systems used in the provision of the Provider Service will incorporate network and software security protocols to protect the privacy and security of your information and will include measures to safeguard data against intentional or unintentional corruption. Personal information that identifies you or contains protected health information will not be disclosed to any third party without your consent, except as authorized by law for the purposes of consultation, treatment, payment/billing, and certain administrative purposes, or as otherwise set forth in your Provider's Notice of Privacy Practices. Use of the Provider Service may include email communications to and from you that may include your protected health information. You understand that Awesome Woman does not and cannot guarantee the security or privacy of the services you use to receive communications, including for example your email service provider.
LABORATORY PRODUCTS AND SERVICES
Certain healthcare services provided to you by Providers as part of the Provider Service may require that you complete an at-home diagnostic test. These diagnostic tests are provided by third-party laboratories, and neither Awesome Woman nor the Provider can guarantee the accuracy or reliability of these tests. These laboratory tests can provide false negative, false positive, or inconclusive results that could impact the Provider’s ability to correctly diagnose or treat your medical conditions. A failure or defect of these tests could also impact the Provider’s ability to correctly diagnose or treat your medical conditions.
By clicking “I Agree”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Digital Platform and as part of the Provider Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following:
- Healthcare and mental health services provided to you by Provider as part of the Provider Service via the Digital Platform will be provided by telehealth. In some cases, your treating Provider may be a nurse practitioner or physician assistant and not a physician.
- Your treating Provider for therapy services will be a mental health professional, such as a licensed counselor.
- If you are experiencing a medical emergency, you will be directed to dial 9-1-1 immediately and the Provider is not able to connect you directly to any local emergency services.
- Certain components of the Digital Platform, including technology that enables you to access and use the Provider Service, may be used while still in a beta testing and development phase, and before such technology is a final and finished product.
- Technology used to deliver care, including the Provider Service, may contain bugs or other errors, including ones which may limit functionality, produce erroneous results, render part or all of such technology unavailable or inoperable, produce incorrect records, transmissions, data or content, or cause records, transmissions, data or content to be corrupted or lost, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from the Provider.
- Certain diagnostic testing services, including laboratory products and services offered through the Digital Platform and as part of the Provider Service, may contain defects, including ones which may limit functionality or produce erroneous results, any or all of which could limit or otherwise impact the quality, accuracy and/or effectiveness of the medical care or other services that you receive from the Provider.
- The delivery of healthcare services via telehealth is an evolving field and the use of telehealth or other technology in your medical care and treatment from Provider may include uses of technology different from those described in this Consent or not specifically described in this Consent.
- Federal and state law requires health care providers to protect the privacy and the security of health information. You are entitled to all confidentiality protections under applicable federal and state laws. You understand all medical reports resulting from the telehealth visit are part of your medical record.
- No potential benefits from the use of telehealth or other technology or specific results can be guaranteed, including any laboratory testing results or related diagnosis or treatment by the Provider.
- Your condition may not be cured or improved, and in some cases, may get worse.
- There are limitations in the provision of medical care or other services and treatment via telehealth and you may not be able to receive diagnosis and/or treatment through telehealth for every condition for which you seek diagnosis and/or treatment.
- There are potential risks to the use of telehealth and other technology, including but not limited to the risks described in this Consent.
- You have the opportunity to discuss the use of telehealth, including the Provider Service, with Provider, including the benefits and risks of such use and the alternatives to the use of telehealth.
- You may elect to seek services from a medical provider other than the Provider and/or with in-person clinics as an alternative to receiving telehealth services.
- You have the right to withdraw your consent to the use of telehealth in the course of your care, without prejudice to any future care or treatment and without risking the loss or withdrawal of any health benefits to which your entitled, but you understand that the Provider utilizing the Digital Platform does not offer in-person treatment. Any withdrawal of your consent will be effective upon receipt of written notice to the Provider, except that such withdrawal will not have any effect on any action taken by Awesome Woman or the Provider in reliance on this Consent before it received your written notice of withdrawal. Any withdrawal of your consent will not affect any other provision of this Consent, and you will continue to be bound by this Consent.
- You understand that the use of the Digital Platform and Provider Service involves electronic communication to and from you of your personal medical information in connection with the provision of telehealth services, including through email. You understand that it is your duty to provide Awesome Woman and the Provider truthful, accurate and complete information, including all relevant information regarding care that you may have received or may be receiving from healthcare and/or mental health providers.
- You understand that the Provider may determine in the Provider’s sole discretion that your condition is not suitable for diagnosis and/or treatment using telehealth technology, including the Digital Platform and the Provider Service, and that you may need to seek care and treatment from a specialist or other healthcare or mental health provider, outside of such telehealth technology.
- Awesome Woman has a commercial relationship with Millennial Benefit Management Corporation d/b/a GeniusRx as its pharmacy partner, Reliant Immune Diagnostics, Inc., as the Provider partner, and additional laboratory partners. You are free to obtain your medical examination from a healthcare provider that is not associated with Awesome Woman. Awesome Woman will use its pharmacy partner to fulfill your order directly to your door. You are free to obtain your prescription from any pharmacy of your choice by contacting our support team.
- You must pay the full amount of the costs associated with use of the Digital Platform, the Provider Service and any other specified costs associated with your telehealth visit, including any prescription you may receive.
If you have a concern about a medical professional, you may contact the Medical Board in your state regarding your concerns.
Additional State-Specific Consents:
The following consents apply to individuals accessing the Digital Platform for the purposes of participating in a telehealth consultation as required by the states listed below:
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: https://medicalboard.iowa.gov/consumers/filing-complaint
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: https://www.in.gov/attorneygeneral/consumer-protection-division/file-a-complaint/consumer-complaint/ .
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, https://kbml.ky.gov/grievances/Pages/default.aspx.
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: https://www.maine.gov/md/complaint/file-complaint
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: https://www.okmedicalboard.org/complaint ; Or, the Oklahoma Board of Osteopathic Examiners’ website.
Texas: 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
Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, https://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint ; Or, the Vermont Board of Osteopathic Examiners’ website, https://sos.vermont.gov/opr/complaints-conduct-discipline/