GENERAL TERMS AND CONDITIONS
By accessing or using our Service, you agree to be bound by this Agreement and to use our Service in accordance with the terms and conditions of this Agreement. If you do not agree to the terms and conditions of use for our Service as set forth in this Agreement, you may not use the Service.
WHAT SERVICE DO WE PROVIDE?
Our Service is designed to enable you to obtain telemedicine consultations and treatment for common medical conditions by providing you access to a licensed healthcare provider (a "Provider"). Once you are assigned one or more Providers through our Service, each of those Providers may be referred to as "your Provider." Your Provider is solely responsible for providing you with medical care.
IS THE SERVICE RIGHT FOR YOU?
In some cases, our Service may not be the most appropriate way for you to seek medical care and treatment. For example, certain medical conditions may require an in-person procedure or very specialized providers not available through our Service. To assist you in determining whether our Service is a fit for your needs, we ask a series of initial questions during registration before we connect you with a Provider. Based on your responses to these questions, we may determine that our Service is not well suited to the particular issue for which you are seeking treatment. In such a case, you will receive an alert notifying you that you will be unable to use our Service for the particular issue you submitted and providing additional information regarding next steps. If this occurs, your registration will remain on file with Practice, but you will not be connected with a Provider nor will you have established a physician relationship with any Provider. You will not be charged for any services provided to you in connection with your submission if we are unable to connect you with a Provider. You can always return to Practice at a later time to submit a request for another condition or issue.
THE MEDICAL CARE YOU RECEIVE FROM YOUR PROVIDER IS NOT A SUBSTITUTE FOR OTHER MEDICAL TREATMENT YOU MAY NEED. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL 911 OR SEEK EMERGENCY MEDICAL HELP.
To use our Service, you are required to set up an account ("Account"). When you set up an Account, you are required to enter your name, email address, password ("Password") and certain other information (e.g., date of birth). You agree that all information you provide is true, accurate, current and complete, and you agree to maintain and promptly update such information to keep it current. You may not transfer or share your Password or Account (collectively, the "Account Information") with anyone.
You are responsible for maintaining the confidentiality of your Account Information and for all activities that occur under your Password or Account. You agree to immediately notify us upon becoming aware of any unauthorized use of your Account Information. Practice reserves the right to take any and all action, as it deems necessary, regarding the security of our Service and your Account Information. Under no circumstances shall Practice be held liable to you for any liabilities or damages resulting from or arising out of your use of our Service, your use of the Account Information, or your release of the Account Information to a third party.
To use our Service, you must also reside in a jurisdiction in which we offer our Service, and you must be at least 18 years of age. If you are between the ages of 13 and 18 and reside in a jurisdiction in which we offer our Service, you may use our Service if your parent or legal guardian has consented to your use of the Service and agreed to the terms of this Agreement in accordance with Practice procedures.
Subject to your compliance with the terms and conditions of this Agreement, we hereby grant you a limited, non-exclusive, nontransferable right to access our Service and use our Service on the mobile device(s) that you own or control solely for your personal non-commercial use.
Use of our Service requires that you comply with acceptable use behavior as determined by Practice. As part of your responsibilities, you agree that you will not: (a) use the Service in any unlawful manner; (b) use the Service in any manner that is harmful, hateful, harassing, abusive, or otherwise offensive to any other person or entity (including your Provider); (c) interfere with or inhibit any other user from using or enjoying the Service; (d) use the Service as a means to distribute unsolicited or unauthorized communications, advertisements or spam; (e) access or search the Service by any means other than the authorized public interface; (f) collect or use any data or Service content that violates any third-party right; (g) create a false identity, impersonate another person or entity, or otherwise misrepresent yourself; (h) breach or otherwise circumvent any security measures incorporated into the Service; or (i) use the Service in any manner that is considered unacceptable by Practice.
FEES AND PURCHASE TERMS
The fees for telemedicine consultations with healthcare Providers are available by inquiry with our Service. Fees are subject to change. It is your responsibility to remain informed about the current rates. Practice will charge you for medical services provided by your Provider, and you agree to pay for all medical services provided to you.
You will provide Practice with a valid credit card or any other method of payment accepted by us ("Payment Provider") when you set up your Account with our Service. By providing Practice with your Payment Provider and associated payment information, you agree that Practice is authorized to invoice your Account at the time any payments are due and charge your designated Payment Provider account. If any payments are subject to sales tax in any jurisdiction, you also agree to pay the required sales tax, and any related penalties or interest. Practice may automatically charge sales taxes for addresses within jurisdictions where such taxes are required. Unless otherwise agreed to by Practice, all fees paid are non-refundable. You are responsible for all fees and charges associated with your Account.
We use a third-party payment processor (the "Payment Processor") to charge your Payment Provider account. The processing of payments in connection with your use of our Service will be subject to the terms, conditions and privacy policies of the Payment Processor and the Payment Provider responsible for your designated method of payment, in addition to this Agreement with Practice. We are not responsible for any errors by the Payment Processor or the Payment Provider.
At present, we will process insurance claims for Med-i-Cal/Medicaid beneficiaries in California who are currently insured and eligible to receive our service. We do not presently process insurance claims for other carriers, nor will your Provider process claims on your behalf. It is solely up to you to contact your health plan, determine whether your coverage applies, and submit a claim if applicable. You are responsible for the full fee charged for Provider care through our Service regardless of whether you later are able to receive reimbursement from your health plan for part or all of the cost.
We alone own all right, title and interest in and to our Service, including all intellectual property rights, and any suggestions, ideas or other feedback provided by you or any other party relating to our Service. Any copy, modification, revision, enhancement, adaptation, translation, or derivative work of or created from our Service shall be owned solely and exclusively by Practice, as shall any and all patent rights, copyrights, trade secret rights, trademark rights, and all other proprietary rights. You shall not remove or permit any third party to remove any proprietary rights from our Service or its contents.
Certain names, logos, and other materials displayed in our Service may constitute trademarks, trade names, service marks or logos ("Marks") of Practice or other entities. You are not authorized to use any such Marks. Ownership of all such Marks and the goodwill associated therewith remains with us or those other entities.
We reserve the right to modify or discontinue, temporarily or permanently, our Service, or any portion thereof, with or without notice. We will not be liable to you or any third party should we exercise that right.
You may delete your Account at any time for any reason by sending us an email or by notifying us through the Service. Practice may terminate your Account and use of our Service at any time for any reason. You understand that termination of your Account may involve deletion of your Account Information from our live databases as well as any content that you uploaded to the Service using such Account, but your Providers, or Practice on behalf of the Providers, may retain your Account Information in accordance with applicable laws and professional standards. You agree that we will not be liable for any termination of your access to our Service or deletion of your Account or content uploaded by you.
OUR SERVICE IS PROVIDED ON AN "AS IS" BASIS. ANY ACCESS TO OR USE OF OUR SERVICE IS VOLUNTARY AND AT THE SOLE RISK OF THE USER. WE DO NOT MAKE ANY EXPRESS OR IMPLIED WARRANTIES, REPRESENTATIONS OR ENDORSEMENTS OF ANY KIND (INCLUDING, WITHOUT LIMITATION, WARRANTIES OF TITLE OR NON-INFRINGEMENT, OR ANY WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE) WITH REGARD TO OUR SERVICE, OR WITH RESPECT TO ANY INFORMATION, PRODUCT, SERVICE, MERCHANDISE OR OTHER MATERIAL PROVIDED ON OR THROUGH OUR SERVICE (INCLUDING ANY CONSULTATIONS OR OTHER SERVICES YOU MAY RECEIVE FROM YOUR PROVIDERS). WE DO NOT WARRANT OR GUARANTEE THE ACCURACY, COMPLETENESS, RELIABILITY, TIMELINESS OR USEFULNESS OF OUR SERVICE. WE DO NOT WARRANT THAT THE SERVICE WILL FUNCTION WITHOUT DELAYS, DISRUPTIONS, INTERFERENCES, IMPERFECTIONS, OR ANY ADVERSE INCIDENT.
LIMITATION OF LIABILITY
IN NO EVENT WILL PRACTICE BE LIABLE TO YOU OR ANY THIRD PARTY FOR ANY DIRECT, INDIRECT, PUNITIVE, EXEMPLARY, INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES [WHETHER IN CONTRACT, TORT (INCLUDING NEGLIGENCE), OR OTHERWISE] ARISING OUT OF THIS AGREEMENT, OR THE USE OF, OR THE INABILITY TO USE, OUR SERVICE, INCLUDING, WITHOUT LIMITATION, ANY INFORMATION MADE AVAILABLE THROUGH OUR SERVICE OR ANY SERVICES PERFORMED BY ANY HEALTHCARE PROVIDERS YOU CONNECT WITH VIA OUR SERVICE (INCLUDING CLAIMS OF MEDICAL MALPRACTICE), EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. IN THE EVENT THE FOREGOING LIMITATION OF LIABILITY IS DETERMINED BY A COURT OF COMPETENT JURISDICTION TO BE UNENFORCEABLE, THEN THE MAXIMUM LIABILITY FOR ALL CLAIMS OF EVERY KIND WILL NOT EXCEED U.S. $100. THE FOREGOING LIMITATION OF LIABILITY WILL COVER, WITHOUT LIMITATION, ANY TECHNICAL MALFUNCTION, COMPUTER ERROR OR LOSS OF DATA, AND ANY OTHER INJURY ARISING FROM THE USE OF OUR SERVICE. SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OF CERTAIN WARRANTIES OR THE LIMITATION OR EXCLUSION OF LIABILITY FOR INCIDENTAL OR CONSEQUENTIAL DAMAGES. TO THE EXTENT THAT WE MAY NOT DISCLAIM ANY IMPLIED WARRANTY OR LIMIT ITS LIABILITIES, THE SCOPE AND DURATION OF SUCH WARRANTY AND THE EXTENT OF OUR LIABILITY WILL BE THE MINIMUM PERMITTED UNDER APPLICABLE LAW.
You agree to the use of electronic documents and records in connection with your registration, future transactions and communications involving our Service. You agree that all agreements, notices, disclosures and other communications that we provide to you electronically satisfy any legal requirement that such communications be in writing.
Any and all provisions of this Agreement that would reasonably be expected to be performed after the termination of this Agreement shall survive and be enforceable after such termination, including, without limitation, provisions relating to ownership, indemnification, limitation of liability and governing law.
LAST REVISED [1/28/18]
WHAT INFORMATION DO WE COLLECT?
We collect any information you provide when you use our Service, including, but not limited to: (1) your name and contact data (such as your e-mail address, phone number, and billing and physical addresses); (2) your login and password; (3) demographic data (such as your gender, date of birth and zip code); (4) your communications with your Providers; and (5) any information you provide when you contact or communicate with us. We may also collect information from you necessary to provide you with services from your Providers, which may include, but is not limited to: (a) payment information; (b) insurance information; and (c) health and medical data (such as previous doctors or other healthcare providers you visited, your reason for visiting a healthcare provider, date of visit, medical history and condition, medications, images or videos, and other medical and health information you share with us).
In addition to the information we collect directly from you, we may also collect certain information from Providers who provide treatment or other services to you in connection with our Service. This information may include, but is not limited to, the Provider's diagnoses, treatment plans (including prescription details) and notes. We may also receive information from third parties that pay for your care or provide you with treatment, laboratory care or prescription medication, which may include, for example, your prescription history, insurance policy, insurance eligibility and coverage, and laboratory test results.
We or our service providers may automatically collect certain information from your device through which you access our Service. This information includes, but is not limited to, your language preferences, your phone number or other unique device identifier (the International Mobile Equipment Identity or the Mobile Equipment ID number), the IP address of your device, the manufacturer, model and operating system of your device, the name and version of our Service you are using, information regarding your browser and information that allows us to personalize our Service. We or our service providers may also collect information about how you interact with our Service and any of our websites to which our Service links or third party websites/applications that link you to our Service, such as how many times you use a specific part of our Service, the amount of time you spend using our Service, how often you use our Service, actions you take in our Service and how you engage with our Service.
We and our service providers will obtain information regarding your location or the location of your device through which you access our Service. Information regarding your location will be obtained directly from you when you provide us with your zip code. Alternatively, our Service may obtain precise information about the location of your device with your express consent. Once you have consented to the collection of the precise location of your device, you may adjust this consent by managing your location services preferences through the settings of your device.
HOW DO WE USE YOUR INFORMATION?
We use information regarding your location or the location of your device through which you access our Service for a number of purposes, including, but not limited to: (a) identifying Providers who may provide you with healthcare services; (b) providing you with a list of nearby pharmacies that may fulfill any prescriptions provided to you by your Provider; and (c) identifying other healthcare providers whom you may visit at the recommendation of your Provider.
HOW DO WE DISCLOSE YOUR INFORMATION?
We may disclose your information to third parties in connection with the provision of our Service or your Provider's provision of services or as otherwise permitted or required by law. For example, we may disclose your information to: (a) third-party service providers that provide services such as the hosting of our Service, data and usage analysis, IT services and infrastructure, customer service, e-mail delivery, auditing and other similar services; (b) Providers to schedule and fulfill appointments and provide healthcare services; (c) Providers to whom you send messages through our Service; (d) Providers for treatment, payment or healthcare operations purposes; (e) third parties as we believe necessary or appropriate to comply with applicable laws; and (f) to a third party in the event of any reorganization, merger, sale, joint venture, assignment, transfer, liquidation or other disposition of all or any portion of our business, assets or stock to such third party. We may de-identify your information and use or disclose that de-identified information for any purpose.
USE BY MINORS
We intend to provide our Service in the United States; accordingly, this Policy, and our collection, use, and disclosure of your information, is governed by U.S. law. We do not represent or warrant that our Service is appropriate or available for use in any particular jurisdiction. If you choose to access or use our Service from outside the United States, you do so on your own initiative and at your own risk. You acknowledge that our Service is subject to U.S. law and consent to the transfer of your information to the United States, which may provide a different level of data security than in the country in which you are located, and you waive any claims that may arise under the laws of your location outside the United States.
We strive to use reasonable physical, technical, and administrative measures to protect information under our control. However, you must keep your Password secure and your Account confidential, and you are responsible for any and all use of your Account. If you have reason to believe that the security of your Account has been compromised, please notify us immediately in accordance with the "Contacting Us" section below.
If you reside in California and have provided your personally identifiable information to us, you may request information once per calendar year about our disclosures of certain categories of your personally identifiable information to third parties for their direct marketing purposes. Such requests must be submitted in writing using the email address in the "Contacting Us" section below.
or by regular mail at:
Elan M. Newman, MD, Inc.
Thanks again for choosing Elan M. Newman, MD, Inc.
LAST REVISED: [1/28/18]
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
- Tell family and friends about your condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and sell your information
- Raise funds
Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1- 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Run our organization
- Treat you
- We can use your health information and share it with other professionals who are treating you.
- Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Bill for your services
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
- Example: We use health information about you to manage your treatment and services.
How else can we use or share your health information?
- We can use and share your health information to bill and get payment from health plans or other entities.
- Example: We give information about you to your health insurance plan so it will pay for your services.
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
Help with public health and safety issues.
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you:
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.
Effective date of this notice: 1/28/18
This Notice of Privacy Practices applies to the following organizations:
Elan M. Newman, MD
Privacy Officer for all organizations:
Elan M. Newman, MD
Patient Consent to Use of Telehealth
In using our Service, you will be consulting with a licensed healthcare provider ("Provider") solely via the use of "telehealth." Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or patient education, and may include, but is not limited to:
- Electronic transmission of medical records, photo images, personal health information or other data between a patient and a healthcare provider
- Interactions between a patient and healthcare provider via audio, video and/or data communications
- Use of output data from medical devices, sound and video files
Provider(s) using our Service will be interacting with you solely via use of our Service. As a result, all of the medical care and treatment you receive from such Providers will be provided via telehealth, and you will not be able to meet with your Provider "in-person."
The electronic systems used in our Service will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.
The use of telehealth by Providers through our Service may have the following benefits:
- Making it easier and more efficient for you to access medical care for the conditions treated by Providers
- Reducing wait times for diagnosis, treatment, and appropriate prescriptions
- Allowing you to obtain medical care and treatment by Providers at times that are convenient for you
- Avoiding unnecessary travel and allowing you to obtain medical care from the comfort and privacy of your home
- Enabling ongoing care and follow-up communication with your Providers on your terms and without travel or missed work/school
While the use of telehealth may provide numerous benefits, there are also potential risks. These risks include, but may not be limited to, the following:
- The information transmitted to your Provider(s) may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making by the Provider(s)
- The inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency care
- Your Provider may not be able to provide medical 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 Providers or the possibility of deficiencies or failures of the technology or electronic equipment used
- In rare instances, security protocols or safeguards could fail, causing a breach of privacy
- Given regulatory requirements in certain jurisdictions, your Provider(s) treatment options, especially pertaining to certain prescriptions, may be limited
- In rare cases, a lack of access to all of your medical records may result in adverse drug interactions or allergic reactions or other judgment errors
BY CONSENTING TO THIS DOCUMENT, I UNDERSTAND AND AGREE TO THE FOLLOWING:
- All medical care and treatment I receive from Providers using this Service will be provided using telehealth and my Providers will not be able to provide any medical care and treatment to me without the use of telehealth.
- The delivery of healthcare services via telehealth is an evolving field and the use of telehealth in my medical care and treatment from Providers may include uses of technology not specifically described in this Patient Consent.
- While the use of telehealth may provide potential benefits to me, as with any medical care service (in-person or using telehealth technology) no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
- There are certain potential risks to me in the use of telehealth, including but not limited to the risks described in this Patient Consent.
- I have the right to withhold or withdraw my consent to the use of telehealth at any time by terminating my use of the Practice Service.
- I have read the Notice of Privacy Practices provided to me, and I understand that my medical information is subject to all applicable laws regarding the confidentiality of healthcare information. I have the right to access and amend my health information in accordance with applicable federal and state laws.
- The use of telehealth involves electronic communication of my personal medical information to Providers who may be located in other areas, including outside of the state in which I reside.
- It is my duty to provide each Provider providing services through this Service all information relevant to my medical care, including all relevant information regarding care that I may have received or may be receiving from other healthcare providers outside of this Service.
- My Provider may determine in his or her sole discretion that my condition is not suitable for treatment using this Service and that I may need to seek medical care and treatment from a specialist or other healthcare provider outside of the Practice Service.
- I am fully responsible for payment for all services provided by Providers or through use of this Service.
BY CONSENTING TO THIS DOCUMENT, I HEREBY:
Represent that I have read this Patient Consent carefully, and that I understand the benefits and risks of the use of telehealth in the medical care and treatment provided to me by Providers using this Service; and
Give my informed consent to the use of telehealth by Providers using this Service under the terms described in this Patient Consent.