Consent to Treatment for Telehealth-Based Services

 

1. Introduction: Telehealth (or Telemedicine, often these terms are used interchangeably) involves the real-time evaluation, diagnosis, consultation, and treatment of a health condition using advanced telecommunication technology, which often includes the use of interactive audio, video, or other electronic media. Vira Health Limited (“Vira”) works with Open Loop Healthcare Partners PC and its affiliates (“Open Loop”) who may provide you services via telehealth. The use of telehealth technology allows the Open Loop provider to see and communicate with you, the patient, in real-time from a remote or distant location.

2. Consent for Telehealth-Based Treatment: By agreeing to this Consent, I voluntarily request and consent to Open Loop physician(s) and/or non-physician practitioners (“Open Loop Providers”), and any associates, technical assistants, and/or other professionals as such Open Loop Providers may deem necessary (“Open Loop Telehealth Providers”), participating in my medical care by utilizing telehealth services.

I understand that Open Loop Telehealth Providers: (a) may conduct their practice in a different location than the one where I may be physically present for such medical care; (b) may not have the opportunity to perform an in-person physical examination of me at the time my telehealth services are provided; and (c) may rely on information provided by me before and during our telehealth services encounter.

I understand that the Open Loop Telehealth Providers’ advice, recommendations, and/or decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimen that may result from electronic transmission issues. I understand that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my knowledge and ability. I also understand that, in the event the telehealth services are interrupted due to a technology problem or an equipment failure, alternative means of communication may be implemented and/or an in-person medical evaluation with my health care provider may be necessary.

I understand that the level of care provided by Open Loop Telehealth Providers is to be the same level of care that is available to me through an in-person medical visit; provided, however, if Open Loop Telehealth Providers determine that the provision of telehealth services will not adequately address my medical needs, the treating Open Loop Telehealth Provider(s) may require me to schedule and attend an in-person medical examination with my health care provider.

I understand that if, after a telehealth services session, I experience any urgent medical symptoms or conditions, I will alert my treating physician or, in the case of an emergency, I will dial 911 or go directly to the nearest emergency room.

I understand that after any telehealth services session, the Open Loop Telehealth Provider(s) must give me guidance regarding any appropriate follow-up care and, if required by law, must share information regarding my telehealth services session with my primary care physician. I hereby authorize Open Loop and my Open Loop Telehealth Provider(s) to share such information, which may include but is not limited to copies of my medical records, a report containing an explanation of the telehealth services provided to me, and/or any evaluation, analysis, or diagnosis of my medical condition made by the Open Loop Telehealth Provider(s).

I acknowledge that I have been given access to a copy of Open Loop’s privacy policy. I understand that I am encouraged to review this policy prior to any consultation, evaluation, and/or treatment by Open Loop Telehealth Provider(s).

I acknowledge that I may file a complaint with any state Medical Board that relates to the provision of any telehealth services.

I have been given an opportunity to ask questions about the telehealth services to be provided to me, including any relevant risks and hazards involved with the provision of such services.

By clicking “accept,” I’m confirming that I consent to the provision of telehealth services by Open Loop Telehealth Providers.