INFORMED CONSENT REGARDING USE OF TELEHEALTH
This Telehealth Consent Policy is effective as of 03/25/2022.
BY CLICKING “I AGREE,” CHECKING A RELATED BOX TO SIGNIFY YOUR ACCEPTANCE, USING ANY OTHER ACCEPTANCE PROTOCOL PRESENTED THROUGH THE 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 CALL 911.
In the event of an adverse reaction to treatment or in the event of an inability to communicate as a result of a technological or equipment failure, contact us at firstname.lastname@example.org or (646) 493-9950.
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 to you by physicians, physician assistants, and/or nurse practitioners (“Providers”) using the online platform owned and operated by Modern Age (the “Service”). In this Consent, the terms “you” and “yours” refer to the person using the Service or a person considered of higher age of majority under applicable state law, “you” and “yours” refer to and include (i) the parent or legal guardian who provides consent to the use of the Service by such minor or uses the Service on behalf of such minor, and (ii) the minor for whom consent is being provided or on whose behalf the Service is being utilized.
Use of Telehealth
Telehealth involves the use of electronic communications to enable providers at different locations to share individual customer information for the purpose of improving customer care. The information may be used for diagnosis, follow-up and/or education, and may include any of the following:
Client health records
Live two-way audio and video
Output data from health devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of customer identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Improved access to care by enabling a customer to remain at a remote site while consulting with practitioners at distant/other sites.
More efficient client evaluation and management.
Obtaining expertise of a distant specialist.
There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate decision making by the providers and consultant(s);
Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal health information;
In rare cases, a lack of access to complete health records may result in interactions or allergic reactions or other judgment errors.
Due to clinician licensing reasons, you have to physically be in the state that your clinician is licensed in during your telehealth visit.
By clicking “I Agree”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent with respect to the following:
I hereby authorize Modern Age to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.
I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.
I accept that the providers can conduct interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.
I understand that I will be responsible for any fee associated with the telehealth appointment.
I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.