Informed Consent for Telehealth Services
All services are provided by licensed physicians and clinicians practicing within independently owned and operated professional practices.
- For patients in FL and WI, this is known as “Gem HealthSpecialty Sleep Services, P.A.” For patients in CA, this is known as “Zinkel,M.D., P.C.” For patients in MN, this is known as “Gem Health Specialty SleepServices of Minnesota, P.A.” For patients in NJ, this known as “Gem HealthSpecialty Sleep Services of New Jersey, P.C.” For patients in NY this is known as “Medical Telehealth Services of New York, P.C.” For patients in TX, this is known as “Gem Health Specialty Sleep Services of Texas, P.A.”
- For patients in CO, this is known as “OpenLoop HealthcarePartners Colorado, PC”. For patients in WV, this is known as “OpenLoopHealthcare Partners, Inc.” For all other states not already mentioned, this is known as “Openloop Healthcare Partners, PC”.
Each such professional practice is referred to herein as the“Professional Practice”.
The Professional Practice provides healthcare services using electronic communications, information technology, and/or remote means of communication (“Telehealth”). The purpose of this form is to obtain your consent to participate in a Telehealth visit with the Professional Practice’s health providers.
By clicking \"I ACCEPT\" below, you understand and agree that:
1. Nature of the Telehealth Visit. During the Telehealth visit:
a. Details of your health information, including but not limited to any and all reports and/or records concerning your medical history, condition, diagnosis, testing, prognosis, treatment, billing information and identity of your health providers(“User Data”),will be discussed with your health provider through the use of interactive video, audio and telecommunications technology.
b. Video, audio, and/or digital photographs may be recorded during the Telehealth visit.
c. Your User Data will continue to be shared via this connection until either you or your health provider terminates this connection.
d. Non-medical technical personnel may be present during the Telehealth visit to aid with the video transmission. You will be informed of their presence and you may request that non-medical personnel leave the Telehealth visit at any time.
e. You understand that: (a) the delivery of healthcare services via Telehealth is an evolving field; (b) the Telehealth visit may include technology (and uses thereof) that are not specifically described in this informed consent; and (c) by agreeing, you consent to the uses of those additional technologies.
2. Limits of Telehealth. Telehealth will be used by a health provider to deliver healthcare services to you. Telehealth may not be as complete as face-to-face treatment and is not intended to replace a full medical face-to-face evaluation by a health provider. You may benefit from Telehealth services; however, results cannot be guaranteed or assured.
3. Telehealth as Appropriate for the Circumstances. It is the health provider's to determine whether or not the use of Telehealth and its enabling technologies, capabilities, and limitations is appropriate for the healthcare services you are seeking.
4. Routine Electronic Messages. Electronic messages sent to the Professional Practice will be reviewed for clinical content and any clinical messages will be directed to a health provider for review.All electronic clinical messages exchanged will be limited to between a health provider and the patient.
5. Medical Information andRecords. All existing laws regarding the confidentiality of your User Data apply to this Telehealth visit. Dissemination of any patient-identifiable images or information from this Telehealth interaction to other entities shall not occur without your consent, unless authorized by law.
6. Right to Care. You are under no obligation to use Telehealth and may withdraw at any time. You have the right to access your User Data and copies of your User Data in accordance with federal and state law.
7. Risks. There are potential risks to using Telehealth technology, including interruptions, unauthorized access, confidentiality, and technical difficulties. You or your health provider can discontinue the Telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation. Health providers will attempt to troubleshoot and re-establish Telehealth connection. If unable to re-establish Telehealth connection, or in an emergency, your health provider will attempt to reach you by calling the phone number you have provided. Risks include, but are not limited to, the following:
a. Information transmitted to your health provider via Telehealth may not in every case be sufficient to allow for appropriate medical decision-making by the health provider.
b. The inability of your health provider to conduct certain tests or assess vital signs in-person may, in some cases, prevent the health provider from making accurate diagnoses, providing appropriate treatments, or identifying the need for emergency medical care or treatment.
c. Your health provider may not be able to provide all of the necessary medical treatment for your particular condition via the Telehealth visit, in which case you should rely on alternative and/or specialized medical care.
d. Delays in medical evaluation/treatment may occur due to unexpected failures in technology associated with providing Telehealth.
e. Although security protocols and safeguards associated with the Telehealth visit are carefully designed to protect data privacy consistent with legal requirements, such protocols and safeguards may fail, causing a breach in data privacy.
f. If our health provider’s treatment options may be limited by regulatory requirements in certain states.
9. Revocation. You make revoke this authorization at anytime by informing your health provider during your Telehealth session or contacting the Professional Practice by email with such instruction; provided, however, that where you revoke this authorization, you will no longer be able to access or use the Telehealth services provided by theProfessional Practice. Absent such a revocation, this authorization will be considered renewed upon each new Telehealth visit with a participating health provider.