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Consent to Treat for Telemedicine

Informed Consent for Treatment, Telemedicine Services, and Financial Agreement / Assignment of Benefits / Release of Information

1. Consent for Diagnosis and Treatment.

By your acceptance below, you hereby request, consent, and authorize medical care given to you or your minor child via telehealth by Mammoth Health, PLLC and its affiliated healthcare providers as set forth below, which may include orders for diagnostic procedures, medications, or treatment the physician(s) or other practitioners involved in your/your child's care consider medically necessary. You understand you have the right to consent or refuse to consent to any proposed procedure or therapeutic course, at any time. You acknowledge that no guarantees have been made to you regarding the outcome of any medical, surgical, diagnostic or therapeutic treatment. You understand that some physicians and other practitioners provide their services as independent contractors to the Practice, are not employees or agents of the Practice, and that the Practice is not liable for their acts or omissions. You agree to receive telehealth services as described in further detail below, which means the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive or asynchronous audio, video, and data communications. You understand that the Practice and its physicians or other practitioners are in a different location than you and that you must accurately report your location during registration. For those states that require it, you can find an explanation of the levels of regulation applicable to clinicians under the STATE REGULATIONS section of this document.

2. Telemedicine

What is Telemedicine

Telemedicine is the use of electronic communications by a health care provider to deliver health care services to you when you are physically located at a different site than the provider. Telemedicine is not a separate medical specialty. Telemedicine providers who provide Services (as defined below) to you will do so as employees or contractors of one of the following professional entities, depending on the state in which you are located at the time of your visit: Mammoth Health, PLLC, a Florida professional limited liability company, Mordkin Medical, PC, a California professional corporation, Mammoth Medical, PC, a New Jersey professional service corporation, and Ajax Medical, PLLC, a New York professional limited liability company.1 The aforementioned entities will be referred to collectively as the “Practice” for purposes of this Consent. The Practice’s telehealth platform may include clinicians with whom you exchange information during a telemedicine visit for diagnosis, treatment, follow-up, coordination of care, and/or educational health care needs (the “Services”). For example, information exchanged during your telehealth encounter may include:

  • Your medical history

  • Laboratory test results

  • Diagnostic information

  • Information about treatment options

When using the Services, you will be treated by and will enter into a clinician-patient relationship with a clinician that is employed by or partnered with the Practice and who is licensed in the state in which Services are offered (“Clinician”). For the purposes of this consent, Clinicians are defined as credentialed healthcare providers, and they may include physicians, nurse practitioners, physician assistants, registered nurses, and other types of healthcare providers. Your provider’s credentials will be made available to you as part of engaging in the Services. If you have any questions about these credentials, pleasedirect them to your telehealth provider.

Your telehealth encounter may take place using one or more telehealth modalities, each of which is designed to provide your Clinician with information needed in order to provide you with appropriate diagnosis and treatment. Depending on your particular condition and other factors, the Services may not be delivered via all of these modalities. Specifically, the Services may be delivered using one or more of the following modalities:

  • A questionnaire to verify your eligibility to receive a laboratory test;

  • An asynchronous store-and-forward encounter that exchanges medical information, including laboratory test results, diagnoses, and treatment options;

  • A live, interactive, audio-only conversation to discuss laboratory test results, diagnoses, and treatment options; and

  • A live, interactive, audio-visual encounter to discuss laboratory test results, diagnoses, and treatment options.

Electronic systems used to deliver the Services will incorporate network and software security protocols to protect the confidentiality of patient identification and laboratory results and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. You agree to hold the Practice and the Clinician harmless against any information or data that is compromised due to such technical failures or other causes.

Expected Benefits and Possible Risks of Telemedicine Services

By your acceptance below, you acknowledge that you understand that some potential benefits of telehealth, results of which are not guaranteed or assured, include: remote access to medical care; medical evaluation and management; and reduced exposure to patients, medical staff, and other individuals at the Practice. You also understand that the potential risks of telehealth include limited or no availability for diagnostic laboratory testing and imaging to assist your provider in diagnosis and treatment; your provider's inability to conduct a hands-on physical examination; and delays in evaluation and treatment due to technical difficulties or interruptions resulting from electronic transmission issues or loss of information due to technical failures. You agree that you will not hold the Practice responsible for lost information due to technological failures. You understand that your provider's recommendation and/or advice and your diagnoses and/or treatment may be based on factors not within his/her control, including incomplete or inaccurate data provided by you. You understand that your provider relies on information provided by me before and during the telehealth encounter and that you must provide accurate and complete information about your medical history, condition(s), and current or previous medical care that is complete and accurate to the best of your ability. IN CASE OF A MEDICAL EMERGENCY, YOU WILL DIAL 911 OR GO DIRECTLY TO THE NEAREST HOSPITAL EMERGENCY ROOM. IF APPLICABLE, CALL THE NATIONAL SUICIDE PREVENTION LIFELINE (1-800-272-8255); OR CONTACT THE CRISIS TEXT LINE (TEXT “GO” TO 741-741).

3. Automated Appointment Reminders.

By supplying your home phone number/mobile phone number/email address, you acknowledge that the Practice or a third-party automated outreach and messaging system may notify you of a pending appointment, missed appointment, lab results, or deliver any other health care message by call, email, or text message. To service your account or collect any amounts you may owe, you consent for Practice or a third party acting on its behalf to call or text you at any phone number associated with your account, including through pre-recorded/automated voice and text messages. You understand that your cell phone carrier may charge you for these text messages and that you will be offered an easy way to opt out of these automated calls or text messages.

4. Use and Release of Medical Information.

You acknowledge that the Practice and its licensed physicians and other health care professionals involved in your care, including Coastline Pharmacy, LLC and the Accredited Laboratories, may use and release your medical information obtained during this visit and the fulfillment of any services, such as the fulfillment of prescriptions or processing of lab tests, for purposes of treatment, payment, and health care operations and otherwise as stated in the Privacy Policy.

As an alternative to a telemedicine consultation, you can make an in-person appointment with your primary care physician or specialty provider.

By selecting “AGREE,” you acknowledge that in addition to the information above, you understand and agree to the following:

  • You must be physically located in your state of residence (as identified in your new patient registration) during your scheduled telemedicine consultation. If you are no longer located in the state used at the time of registration, you are obligated to notify the Clinician immediately and no later than at the beginning of your telemedicine consultation.

  • You have had the alternatives to a telemedicine consultation explained to you, and it is your voluntary choice to participate in this telemedicine consultation.

  • You understand there is no guarantee you will be treated by a Clinician. The Clinicians reserve the right to deny care for potential misuse of Services or for any other reason if, in the professional judgment of the Clinician, the provision of Services is not medically or ethically appropriate.

  • You understand there is no guarantee that you will be given a prescription by the Clinician.

  • You understand that you cannot use the Services to get prescriptions for non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse or that otherwise cannot be appropriately prescribed using the Services.

  • You understand that you can choose to refuse or end the telemedicine service at any time without affecting your right to future care and treatment.

  • You understand that federal and state law requires Clinicians to protect the privacy and the security of health information. You understand that the Practice will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other clinicians who may be located in other areas, including out of state.

  • You understand that you may request that your Clinician forward a copy of your medical records to your primary care provider, and in such cases, you expressly consent to the sharing of such medical records with your primary care provider.

  • You understand that you may request that your Clinician assist you with identifying options for non-emergency follow-up care needs, to the extent that you want or need in-person health care services.

  • You understand that you may register any complaints regarding the Services or your Clinician through Customer Support via the “Contact Us” section of our website at LetsGetChecked.com or with the applicable state professional licensing board.

  • You understand that you or your Clinician can discontinue the telemedicine visit at any time if the videoconferencing connections or other telehealth modalities are inadequate to exchange medical information, transmit diagnoses, or review treatment options.

  • You understand that you will not physically be in the same room as your Clinician.

  • You understand there are potential risks to using telemedicine technology, which, while unlikely, may include loss of confidentiality, integrity, and availability of information, and/or other technical difficulties with Services.

  • You understand that your healthcare information may be shared with other individuals for scheduling, treatment, and/or billing purposes. Under no circumstances will your identifiable patient information from the telehealth encounter, including images, be shared with researchers or other entities without your written consent.

  • You have the right to object to the videotaping or other recording of a telemedicine visit. You also agree not to record a telemedicine visit without your Clinician’s permission.

  • You understand that you have the right to request a copy of the medical record that is created as a result of using the Services which will be provided to you at reasonable cost of preparation, shipping and delivery.

  • In an emergency situation, you understand that you should immediately contact emergency services.

  • You understand that you will be responsible for any copayments, coinsurances, deductibles, and/or non-covered services that apply to your telemedicine visit (if applicable).

  • You understand that it is your duty to inform your Clinician of any relevant interactions regarding your care that you may have with other healthcare providers.

  • You understand that you have the right to withhold or withdraw your consent to the use of telemedicine in the course of your care at any time, without affecting your right to future care or treatment. You understand that you may suspend or terminate use of telemedicine at any time for any reason or for no reason.

  • You understand this Informed Consent and consent, on your own behalf to receive Services.

Treatment and Confidentiality of Minors

In accordance with state laws, consent for treatment of a minor can only be authorized by a current legalguardian for the minor. If the parents of a minor are separated, treatment is provided to the minor onlywith the written consent of both parents.If the parents of the minor are divorced,consent for treatment of the minor may be given by the parent authorized to make medical decisions for the minor. If a court of law has ordered that medical decisions for the minor are to be made jointly by the minor’s parents, then consent of both parents is required for treatment of the minor. In the case of minors, as defined by state law, parents may request information about their child’s diagnosis or treatment. While release of this information will be provided, it is best that the process be a collaborative one involving the minor, parent, and Clinician in order to maintain the rapport established between the minor and clinician since rapport is vital to treatment success. Therefore, unless there is a safety concern, the minor would be consulted about the disclosure and encouraged to share the information with the parent first in order to establish better communications within the family structure.

Financial Agreement

You understand that you are unconditionally financially responsible to the Practice as the patient, parent, guardian, conservator, or insured for all charges not covered by your insurance plan. You acknowledge that you are responsible for verifying the extent to which your insurance plan covers the telemedicine services offered by the Practice. You promise to pay the Practice for all services rendered by a Clinician, whether or not such services are covered under the terms of your insurance coverage, including but not limited to, co-payments, co-insurance, deductibles, and non-covered services. If you do not have insurance coverage, you understand that the charges for medical services are your personal responsibility and agree to make payment for any such amounts. If you believe any of the charges you have been incurred are incorrect, you must immediately contact us inwriting regarding the amount in question to be eligible to receive a refund. You irrevocably waive your right to challenge the accuracy of any charge, or otherwise receive a refund, if you fail to notify us in writing within fifteen(15) calendar days after the charge, that you believe the charge is inaccurate(setting forth an explanation of why). If the Practice does not receive payment within thirty (30) days from the date such balance is due, the bill may be turned over to an attorney or collection agency. If so, you agree to pay all reasonable collections costs including attorney’s fees and/or collection fees in addition to the amounts owed for services.

Assignment of Benefits

Further, if you are entitled to receive healthcare benefits under any insurance policy from any person or organization, you hereby assign to the Practice all of your rights, title and interest in those benefits for payment of your bills. You understand that you are responsible for knowing the terms and conditions of any applicable insurance coverage, and certify that the information given regarding your insurance is accurate and current to the best of your knowledge. You agree not to attempt to cash or negotiate insurance checks sent directly to you or to the insured and further agree to promptly endorse and deliver to the Practice any insurance checks, upon receipt. You hereby authorize the Practice to act on your behalf in regard to filing any appeals for insurance. To the extent applicable, you certify that any information you provide in applying for Medicare or Medicaid is correct. You hereby request payment of authorized benefits to be made on your behalf to the Practice by the Medicare or Medicaid program.

Release of Information

Additionally, you authorize the Practice to process claims for payment by your insurance carrier on your behalf for covered services provided to you during this telemedicine consultation. You authorize the Practice to release your medical information to (A) any third-party payor or insurance company responsible for paying your medical bill; (B) any third parties retained by the Practice for the purposes of obtaining payment of your bill; (C) any health care facility or physician to which you are transferred or referred to permit continuity of care; (D) any governmental agency or government entity as may be required by law; or (E) to facilitate applications for financial assistance or other determination of your eligibility for Medicare, Medicaid, and other benefits to which you may be entitled. As permitted or required by applicable state and federal laws, the information in your medical record that may be released to the entities listed above includes, but is not limited to: (1) information about your medical condition and your treatment; (2) information about serious communicable diseases and infections, including information about sexually transmitted diseases, tuberculosis, hepatitis, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and any other disease or medical condition; (3) any vaccination or immunization administration history; (4) results of toxicology screening and information regarding treatment for substance abuse; (5) information regarding sexual assault or evidence thereof; (6) developmental disability, mental health, psychological and social information, including communications made to or from you by a psychiatrist, licensed psychologist, nurse practitioner, physician's assistant, therapist, social worker, and/or other behavioral health clinician; (7) information regarding genetic and genomic testing, including the tests you received and your results; (8) information related to your insurance plan, policy number and insurance coverage available to you; and (9) personal information about you, such as your address, telephone number and Social Security number. You understand that, if this information is disclosed to a third party, the information may no longer be protected by state or federal privacy regulations and may be re-disclosed by the person or entity that receives the information, in accordance with applicable law.

Revocation

You understand and agree that this Informed Consent, Financial Agreement, Assignment of Benefits, and Release of Information will remain in effect unless you revoke your authorization in writing, except to the extent that the Practice has already taken action in reliance upon it. Written revocations must be sent via email to DPO@LetsGetChecked.com or sent via physical mail certified and delivered to the Practice at 2300 Windy Ridge Pkwy SE STE 850S, Atlanta, GA 30339. Such revocation will be effective upon receipt, but you agree to remain personally liable for all financial commitments incurred prior to such revocation. Any prior Informed Consent, Financial Agreement, Assignment of Benefits, and Release of Information forms that may have been executed, will be replaced by this legal document. You further agree that this form, as executed, is controlling in any disputes related to the above stated terms.

STATE REGULATIONS:

Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.64.364).

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (A.R.S. § 12-2291.)

California: You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. (Cal. Welf. & Inst. Code Ann. § 14132.725(d)).

Colorado: You are informed that if you want to register a formal complaint about a provider, you should file at https://dpo.colorado.gov/FileComplaint.

Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906).

D.C.: You have been informed of alternate forms of communication between your and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10).

Georgia: You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).

Iowa: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://medicalboard.iowa.gov/consumers/filing-complaint

Idaho: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://elitepublic.bom.idaho.gov/IBOMPortal/AgencyAdditional.aspx?Agency=425&AgencyLinkID=650Il

Illinois: You have been informed that if you want to register a formal complaint about a provider, you should visit the Illinois Division of Professional Regulation at https://www.idfpr.com/admin/DPR/DPRcomplaint.asp

Indiana: As a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.in.gov/attorneygeneral/2434.htm.

Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A). You understand that the complaint process may be found here: http://www.ksbha.org/complaints.shtml

Kentucky: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://kbml.ky.gov/grievances/Pages/default.aspx

Louisiana: You understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511).

Maine: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here:https://www.maine.gov/md/discipline/file-complaint.html

Maryland: The knowledge, experiences, and qualifications of the consultant providing data and information to the provider of the telehealth services need not be completely known to and understood by the provider. The quality of transmitted data may affect the quality of services provided by the provider. Changes in the environment and test conditions could be impossible to make during delivery of telehealth services. Telehealth services may not be provided by correspondence only. (Md. Code Regs. 10.41.06.04). You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: https://www.mbp.state.md.us/forms/complaint.pdf.

Nebraska: If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05). You have been informed that if you want to register a formal complaint about a provider, you should visit: https://dhhs.ne.gov/Pages/Complaints.aspx

New Hampshire: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

New Jersey: You understand you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. (N.J. Rev. Stat. Ann. § 45:1-62).

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-11-09(C).

Oklahoma: You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here:http://www.okmedicalboard.org/complaint.

Board of Osteopathic Examiners can be found at: https://www.ok.gov/osboe/faqs.html

Rhode Island: If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines).

South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. (S.C. Code Ann. § 40-47-37).

South Dakota: You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3).

Tennessee: You understand that you may request an in-person assessment before receiving a telehealth assessment if you are a Medicaid recipient.

Texas: You understand that your medical records may be sent to your primary care physician. (Tex. Occ. Code Ann. § 111.005). You have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us

Utah: You understand (i) any additional fees charged for telehealth services, if any, and how payment is to be made for those additional fees, if the fees are charged separately from any fees for face-to-face services provided in combination with the telehealth services; (ii) to whom your health information may be disclosed and for what purpose, and have received information on any consent governing release of your patient-identifiable information to a third-party; (iii) your rights with respect to patient health information; (iv) appropriate uses and limitations of the site, including emergency health situations. You understand that the telehealth services meets industry security and privacy standards, and comply with all laws referenced in Subsection 26-60-102(8)(b)(ii). You were warned of: potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold the provider harmless for such loss. You have been provided with the location of telehealth company’s website and contact information. You were able to select your provider of choice, to the extent possible. You were able to select your pharmacy of choice. Your are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. (Utah Admin. Code r. 156-1-603).

Virginia: You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless Practice for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

Vermont: You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult.

You have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; Board of Osteopathic Examiners can be found at: https://www.sec.state.vt.us/professional-regulation/file-a-complaint-employer-mandatory-reporting.aspx