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  • Childre / Dependents
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  • Preferred Pharmacy
  • PATIENT CONSENT FORM CONSENT FOR TELEMEDICINE CONSULTATION

    I hereby authorize SM Concierge Medicine, its subsidiaries/affiliated/contracted entities (“Company”), and its related and/or contracted physicians, other health care professionals, employees, and contractors (the “Professionals”), to use telehealth* in the course of the telemedicine consultation utilizing our proprietary system, methods, and protocols (the “Consultation Services”). I HEREBY REQUEST AND CONSENT TO THE CONSULTATION SERVICES TO BE PROVIDED BY COMPANY AND THE COMPANY PARTIES. I understand that telehealth involves the communication of my medical information, both orally, in writing, and visually, to physicians and other healthcare practitioners at other locations. I understand that the physician-patient relationship, if any, between myself, Company, and the Professionals, is explicitly limited in nature to the Consultation Services, and nothing else. I further understand that, even if I have health insurance of any form, that the Consultation Services are private-pay and are likely not coverable by such insurance. I agree to NOT bill any insurer that may cover me for the Consultation Services, and acknowledge that Company and the Professionals will not be billing any 3rd party for the Consultation Services.
    Consultation Services Specifically

    1. PREGNANCY AND BREASTFEEDING: I UNDERSTAND THAT IF I AM PLANNING TO BECOME PREGNANT, AM CURRENTLY PREGNANT, OR AM BREASTFEEDING, THAT I WILL: (A) ADVISE COMPANY AND THE COMPANY PARTIES OF THIS; AND (B) ASK MY OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE COMPANY PARTIES ARE ACCEPTABLE DURING THIS PERIOD OF TIME.

    2. OUTCOMES NOT GUARANTEED: Neither Company nor the Professionals guaranty outcomes based on utilizing the Consultation Services or products or medicines associated with the Consultation Services. I acknowledge that my condition for which I am seeking treatment may get worse, and I am subject to the risks further described below, including risks that my condition may worsen. I agree that I will not be entitled to a refund or recompense from Company or the Professionals for any reason, including poor outcomes.

    3. Company Does Not Provide or Pay For Prescribed/Recommended Medicines, or Other Courses of Treatments: I understand that the fees that I pay Company and/or the Professionals DO NOT include the costs of any prescription drugs or medicines, or other courses of treatment, that may be recommended/prescribed by Company or the Professionals. I understand that I am wholly responsible for the payment of any such drugs or medicines or treatments.

    4. I understand that all health care treatments can have potential adverse side effects and I accept responsibility for these potential adverse outcomes.

    5. If adverse effects are noted, I understand that it is my responsibility to stop all treatments recommended by the Professionals, and to report any adverse side-effects to Company, the Professionals, and to go to the nearest Emergency Room if necessary.

    6. I understand that once the Professionals decide on the treatments and medications to be issued, if any, it is my responsibility to read and understand the side-effect profile of the medications and the adverse drug interactions of the medications and other medications I may be taking.

    7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than the health care professional in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

    8. I understand that I will be responsible to pay the Company according to the fee schedule included in the Private Pay Agreement.


    Telehealth

    1. I understand that while the Professionals will make every attempt to accurately diagnose and treat my healthcare condition for which I am seeking a teleconsultation, there is still some inherent uncertainty and inaccuracy with delivering healthcare over the Internet. I accept that the “physical exam” portion of the online visits, if any, will be done via pictures, twoway audio/video consultation, questionnaire, relying upon my medical records, or otherwise, which is an accepted method for teleconsultations and is agreed to be an appropriate prior examination made in good faith. I accept this, with all potential benefits and consequences, and deem this method of physical examination appropriate and complete.

    2. I understand that I have the option to withhold or withdraw my consent to receive the Consultation Services via telehealth at any time, but that doing so will cause Company and the Professionals to discontinue providing future care or treatment, it being acknowledged that Company and the Professionals will only be treating me via telehealth methodologies. In such case, I understand that I will need to seek treatment elsewhere.

    3. I understand the potential benefits of telehealth, which include having access to medical specialists and additional medical information and education.

    4. I understand the potential risks and consequences of telehealth, which include that because of my specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment, and the telehealth care provider may not be able to accurately diagnose my condition due to limitations inherent in using a non-face-to-face encounter. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a facetoface visit with a physician.

    5. I understand that all laws about the confidentiality of medical information apply to telehealth information.

    6. I understand that all laws about patient access to medical information and copies of medical records apply to telehealth records.

    I have read and understand the written information provided above. I agree that the information provided above adequately explains the Consultation Services to me, along with the risks and benefits of said Consultation Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full by Company, the Professionals, and/or their designees. Further, I represent that I have read and fully understood and agreed to: (i) the Company Private Pay Agreement; (ii) the Company Notice of Medical Information Privacy Practices; and (iii) the Company Privacy Policy;


    THIS FORM MUST BE PLACED IN THE MEDICAL RECORD. A COPY MAY BE GIVEN TO THE PATIENT.

    "Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.

    Online prescriptions will only be issued when indicated and approved by a physician, and as permitted by law in your state.


  • Type your full name and date to accept the terms listed above:
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