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Informed Consent to Treat, Authorization & Release

 

 

1. Consent to Medical Care

I (or on behalf of my child or an individual to whom I provide guardianship) hereby authorize the health care providers of Elemedical Healthcare), d/b/a ELEMED™ (the “Practice”) and their providers (“Provider(s)”), to provide medical services (“Medical Services”) which in their professional judgment is deemed necessary to diagnose and/or treat the conditions that have brought about my seeking medical care from the Practice. I acknowledge that no guarantees are made to me concerning the outcomes of the treatment rendered by Providers.

 

 

For purposes of this Informed Consent to Treat, Authorization & Release (the “Agreement”), “Medical Services” refers to medical treatment by providers via telemedicine and/or in-person, and may include but is not limited to:

 

 

– Wellness Visits
– Urgent Care Visits
– IV Therapy and Treatment
– Ultra Sound, EKG, and Other Diagnostics
– Injury and Illness Treatment and Care

 

 

I acknowledge that no guarantee can be made or has been made as to the results of treatments or examinations and I understand that all medical treatments contain inherent risks. I acknowledge that the Providers may disclose my/the patient’s Personal Health Information (“PHI”) with my/the patient’s primary care provider and/or other health care providers, if deemed medically necessary by the Providers.

 

 

Practice and the Providers DO NOT address medical emergencies via Telehealth or otherwise.

 

 

IF YOU HAVE A MEDICAL EMERGENCY, IMMEDIATELY CALL YOUR DOCTOR OR DIAL 911.
 

 

2. Consent to Telehealth

Telehealth involves the delivery and facilitation of health and health-related services, including medical care, via telecommunications and digital communication technologies, including but not limited to through websites, audio, video, and asynchronous data communications.

I consent to receiving medical care via Telehealth platforms and understand that there are certain risks associated with receiving care through such platforms, including but not limited to:

 

 

• Improved access to care while the provider consults at distant/other sites.
• Telehealth can make access to medical care easier, more efficient, and less expensive.
• You can obtain medical care or other services and treatment by Provider(s) at times that are convenient for you.

 

 

During my scheduled visit, a Provider may be with me, in-person, to facilitate the provision of medical care and to assist in the provision of telehealth services provided by another Provider.

 

 

Confidentiality

The Practice has a legal and ethical responsibility to make best efforts to protect all communications that are a part of telehealth services. The nature of electronic communications technologies, however, is such that it cannot guarantee that communications will be kept confidential or that other people may not gain access to confidential communications.

 

 

Security

The Practice’s Telehealth platforms and systems incorporate network and software security protocols to protect the security of protected health information. Though every effort is made to ensure confidentiality, the limitations and risks in Telehealth include, for example: public discovery, possibility of hackers, disruption by technical failures, household noise or interruptions, risks of being overheard by persons near me, and other potential risks outside of the Practice’s control. Even with using best practices with telehealth/telemedicine services, any information transmitted via the internet may not be 100% secure. I also understand that miscommunication between myself and the Providers may occur via telehealth or telemedicine services. Furthermore, I understand and acknowledge that, in some instances, telehealth and telemedicine services may not be as effective or provide the same results as in-person care or Services. If the Providers determine that in-person care is necessary, the Practice reserve the right to refuse to provide such services if doing so would not be in the patient’s best interest.

 

 

Recording

Telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent.

 

 

3. Terms of Service & Privacy Policy Acknowledgment

I agree to Practice’s Terms of Use and Privacy Policy.

 

 

4. Financial Authorization and Guarantee

I understand that the Practice does not participate in any insurance plans, including Medicare or Medicaid, and does not accept any health insurance whatsoever in connection with the Medical Services, and that the Medical Services are 100% “self-pay.”

I acknowledge and agree that either: (1) I do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or (2) have health insurance but do not want to use any insurance benefit for the Medical Services, acknowledging that the Company does not accept any health insurance in connection with the Medical Services. I further understand that if I try to obtain reimbursement from my insurance plan after I have received and paid out of pocket for the Medical Services, that there is no guarantee that my insurance plan will provide any such reimbursement to me.

 

 

I accept full and complete financial responsibility, on a “self-pay” basis, for the cost of all Medical Services rendered to me by the Practice, its Providers, and such other services that may be rendered by the Practice, its Providers, and/or ELEMED. I acknowledge that the charges for such Medical Services were disclosed to me in advance and that I have selected those services and accept full financial responsibility for payment for same.

 

 

I agree to pay all costs for the Medical Services at the time of scheduling such Medical Services via the Apps (as that term is defined more fully in the Terms of Use and Privacy Policy ), and understand that I cannot cancel the Medical Services more than 30 (thirty) seconds after I book or schedule such services, and that I will not be entitled to any refunds if I seek to do so . I further agree to pay all costs for any additional or “add on” Medical Services I may receive during a scheduled appointment, but which were not ordered at the time of booking, and consent to ELEMED and/or the Practice charging such costs to my credit card on file with ELEMED and the Practice.

 

 

5. Communications

I consent to be contacted by phone, text, email, and mail for reasons related to my care, services provided, and for marketing of other services. I understand that I can opt out from those communications at any time by contacting info@elemedical.com. I acknowledge receipt of the Practice’s HIPAA Notice of Privacy Practices.

 

 

6. Consent to Obtain Medication History

By signing this Consent I agree that the Providers may request and use my prescription medication history from other healthcare providers and/or third-party pharmacy benefit payors for treatment purposes. I understand that the Providers may obtain my medication history by utilizing electronic information exchange. This medication history may help the Providers determine my appropriate medical treatment and avoid potentially dangerous drug interactions. I understand that the medication history obtained will become a part of my electronic medical record. I understand that the medication history obtained may not be complete, and that I should still discuss my full medication history with the Provider.

 

 

7. Release

I recognize that there are inherent risks associated with the Medical Services. I waive any and all rights, claims, or causes of action of any kind whatsoever arising out of my participation in obtaining Mobile Medical Services, and do hereby release and forever discharge ELEMED, the Practice and their Providers, employees, agents, representatives, successors and assigns, for any and all physical, emotional or economic loss that I or the patient may suffer as a direct result of such participation. I agree to indemnify and hold harmless ELEMED, the Practice, the Providers, and their employees, agents, representatives, successors and assigns, against any and all claims, suits, or actions of any kind whatsoever for liability, damages, compensation, or otherwise brought by me, the patient, or anyone on my or their behalf, including reasonable attorney’s fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my or the patient’s behalf.

 

 

8. Dispute Resolution

I acknowledge, understand, and agree that any and all disputes I may have with ELEMED, the Practice, and/or the Providers regarding the Medical Services or that are otherwise related to this Agreement, whether in contract, tort, or otherwise, including but not limited to claims of medical malpractice, wrongful death, loss of consortium, emotional distress, and/or breach of contract (“Disputes”), shall be resolved exclusively and finally only by binding arbitration, on an individual basis, and that I expressly waive my right to arbitrate on a representative, class, or class wide basis, and/or to litigate any such Disputes in any way.

Any arbitration will be administered by the American Arbitration Association (“AAA”) in accordance with the Arbitration Rules (the “AAA Rules”) then in effect, except as modified by this Section Dispute Resolution and Binding Arbitration. (The AAA Rules are available at adr.org or by calling the AAA at 1-800-778-7879.) The Federal Arbitration Act will govern the interpretation and enforcement of this section.

The arbitration hearing shall take place in the state of New Jersey before a single arbitrator. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. The arbitrator will have exclusive authority to resolve any dispute relating to arbitrability and/or enforceability of this arbitration provision, including any unconscionability challenge or any other challenge that the arbitration provision or the Agreement is void, voidable or otherwise invalid. The arbitrator will be empowered to grant whatever relief would be available in court under law or in equity. Any award of the arbitrator will be final and binding on each of the parties and may be entered as a judgment in any court of competent jurisdiction.

 

 

I agree that any arbitration shall be on an individual basis only. In any Dispute, I WILL NOT BE ENTITLED TO JOIN OR CONSOLIDATE CLAIMS BY OR AGAINST OTHER PERSON OR ENTITY IN COURT OR IN ARBITRATION OR OTHERWISE PARTICIPATE IN ANY CLAIM AS A CLASS REPRESENTATIVE, CLASS MEMBER OR IN A PRIVATE ATTORNEY GENERAL CAPACITY. The arbitral tribunal may not consolidate more than one person’s claims and may not otherwise preside over any form of a representative or class proceeding. The arbitral tribunal has no power to consider the enforceability of this class arbitration waiver and any challenge to the class arbitration waiver may only be raised in a court of competent jurisdiction. I further understand and agree that there is no right to an appeal or a review of an arbitrator’s award as there may be in connection a judge or a jury’s decision in litigation.

 

 

If any provision of this arbitration agreement is found unenforceable, the unenforceable provision will be severed, and the remaining arbitration terms will be enforced.

 

 

All Disputes or other matters arising out of or relating to this Agreement or that are related to the Medical Services shall be governed by and construed in accordance with the internal laws of the State of New Jersey without giving effect to any choice or conflict of law provision or rule and shall be venued in ARBITRATION in New Jersey. If any provision of this Agreement found to be invalid by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of this Agreement, which shall remain in full force and effect without regard to the invalid portions.

 

 

9. Understanding

I have read and understand the terms of this Agreement and I have had an opportunity to ask questions about it. By my signature, I agree to the terms herein and authorize the Practice and the Providers to use or disclose my information in the manner described above. I acknowledge that if I decline to sign this document, I will not be eligible to receive the Medical Services referenced herein. If applicable, I hereby acknowledge by my signature that I am authorized as a guardian, parent or legal authorized representative of the child or charge named.